CLIENT HEALTH QUESTIONNAIRE
Date
*
 -
Month
 -
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prior to the start of my service, I confirm that:
*
I do not have a pending COVID-19 test.
I have not been diagnosed with or cared for anyone with COVID-19 in the past 2 weeks.
I have not shown signs or been in close contact with anyone that is exhibiting these symptoms: COUGH, FEVER/CHILLS, SHORTNESS OF BREATH, DIFFICULTY BREATHING, SORE THROAT, LOSS OF TASTE OR SMELL, FATIGUE, HEADACHE, CONGESTION, OR RUNNY NOSE, NAUSEA OR VOMITING OR DIARRHEA
I have not traveled outside of my immediate daily routine for the past two weeks.
If I begin to show symptoms of COVID-19 within the next two weeks, I will contact my stylist.
I will follow all posted salon rules to keep myself, my stylist, and those around me safe.
Signature
*
Submit
Should be Empty: