COVID-19 Health Waiver
Client Name
First Name
Last Name
Have you experienced symptoms, or been treated for the Coronavirus in the last 30 days?
*
No
Yes
Have you been in contact with someone affected by the Coronavirus in the last 14 days?
*
No
Yes
Have you traveled outside of the country in the last 14 days?
*
No
Yes
Have you remembered to bring a face mask that loops behind your ears, and not your head?
*
No
Yes
Do you understand your service can be denied if you show concerning signs and symptoms (cough, shortness of breath, fever above 100 degrees).
*
No
Yes
Client Signature
*
Submit
Should be Empty: