Details Barbershop

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Do you have any of the following symptoms?:*

Have you been in contact with anyone with COVID-19 or symtoms of COVID 19 in the past 14 days?*

YesNo

Have you traveled anywhere outside the United States in the past 14 days?*

YesNo

Have you been directed to quarantine by the RIDOH or healthcare provider in the past 14 days?*

YesNo

If you have answered "YES" to any of the questions above, and you cannot explain these symptoms by known allergies or non-infectious illnesses, then you cannot enter this building for the safety of others

I understand the potential health risks asociated with unintentional exposure to the COVID-19 virus. By signing below, I agree to release this facility and it's staff from all liability concerning any possible exposure and health risks associate with COVID-19 I may encounter due to my procedure.

Signature*

Todays Date*

COVID-19 Screening Form