COVID-19 Health Questionnaire
Client Details
This questionnaire is designed for the safety and wellbeing of clients and staff within Halo Hair Congleton
These questionnaires will be held for 28 days under government guidelines
Contact Details
Name
*
First Name
Last Name
Date Of Birth
*
/
Day
/
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
Used for any updates regarding appointment times
Phone Number
Landline
Email
*
Used for any updates regarding appointment guidelines and confirmations
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Appointment Details
Date/Time Of Appointment
*
-
Day
-
Month
Year
Date Picker Icon
Hour Minutes
Name Of Stylist For Upcoming Visit
*
Please Select
Clare Vickers
Samantha Rutter
Katie Copeland
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Your Heath
Have you experienced any of the following symptoms within the last 7 days?
*
Persistent Cough
Shortness of breath
Temperature of 38 degrees celsius or above
Other symptoms such as a sore throat or loss of smell/taste
Non of the above
Have you or anyone in your household come into contact with any suspected, probable or confirmed COVID-19 cases within the last 14 days?
*
Yes
No
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International Travel
Have you or anyone in your household had any travel outside of the UK within the past 14 days?
*
Yes
No
Name
First Name
Last Name
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Halo Hair Congleton COVID Operating Policy
To prevent the spread of contagious viruses including COVID-19 and to help protect each other, I understand that I will have to follow the salon's COVID SAFE guidelines
*
by checking this box I understand and accept this statement
I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when visiting Halo Hair Congleton and the information within this document can be held on record for the UK GOV Track & Trace service if needed and to contact you regarding any appointment relating matters
*
Yes I agree to the all of the above statement and the use of my personal data
Signature
*
Submit
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