ALPHA D Hair Salon-Daily Screening
customers are required to complete this daily screening prior to participation our service.
Do any of below these questions apply to you YES, Please contact us for cancellation or reschedule your appointment.
Location *
First Name *
Last Name *
Phone Number *
Email *
1. Do you have any of the following symptoms: fever, cough, shortness of breath or difficulty breathing? *
2. Do you have at least two of these symptoms: chills, repeated shaking with chills, headache, sore throat, new loss of taste or smell? *
3. Have you, or anyone in your household, returned from trip outside of the country within the last 14 days? *
4. In the past 14 days, have you been in contact with someone with, or suspected to have, COVID-19? *
5. In the past 14 days, have you been directed by Public Health to self-isolate? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy