COVID-19 SCREENING CHECKLIST FOR CLIENTS
Purpose: Based on the US Center for Disease Control Guidelines, service providers, daily, are encouraged to screen all clients for signs of respiratory illness accompanied by fever.

Instructions: All clients PERCEPTION ORGANIC SPA’S building must be asked the following questions below. Perception Organic Spa will maintain this record for 14 days from completion of this form and have this form available upon request from the Public Health Department.
Email *
Full Name *
Date *
MM
/
DD
/
YYYY
Time
:
By checking this box, I pledge to provide only correct and truthful information when completing this screening.
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