COVID-19 Questionnaire Record
Any fields marked with * are compulsory
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
County / State
Post / Zip Code
E-mail
*
example@example.com
Date of Birth
-
Day
-
Month
Year
Date
Please answer the following questions as accurately as possible.
Please enter the following information
Have you felt unwell in the last two weeks?
Yes
No
Do you have a fever (>37.5)?
Yes
No
Do you have a new, persistent cough?
Yes
No
Do you have a sore throat?
Yes
No
Have you lost your sense of smell or taste?
Yes
No
Have you been in contact with somebody who has any of these symptoms?
Yes
No
Have you travelled to an area at high risk of COVID-19, nationally or internationally?
Yes
No
Do you work in a hospital / care home or healthcare facility?
Yes
No
Have you been diagnosed with COVID-19?
Yes
No
Do you live in a household with somebody who has been diagnosed with COVID 19 or has symptoms ?
Yes
No
Client Declaration
Please enter the following information
*
I knowingly and willingly accept to have services performed by my lash artist during the COVID-19 pandemic and agree that my lash artist is not responsible for risks associated with receiving treatments during the COVID-19 pandemic.
I understand and accept that I will be required to adhere measures to restrict the transmissions of COVID-19.
I understand that COVID-19 has a long incubation period with some carriers not showing symptoms, but will still be highly contagious.
I will be required to adhere to my lash artists hygiene policy.
I will adhere to any instructions from my lash artists regarding social distancing during the appointment.
Please enter any other information you think we should know.
Signature
1
Submit
Should be Empty: