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?

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

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

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