Covid Questionnaire For Clients

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Do you have any of the following symptoms?

In the best of your knowledge, in the past 14 days, have you contacted a person who might have been COVID positive?

YesNo

Please be aware:

Immediately wash your hands for at least 20 seconds right after you enter the facility
Do not shake hands or do not touch/hug others
Keep 2m distance with other clients
Wear a mask

By signing this form, I hereby read and understand the facility rules and declare that the information I have given above is correct and valid.

I, also, acknowledged the potential risk to contract the COVID-19 disease during services provided in this facility and I voluntarily agreed to accept services. I, also, accept that the facility cannot be held responsible for the transmission of COVID-19.

Date

Signature