Customer Wellness Survey
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
In the past 14 days, have you traveled outside of your hometown to any foreign country or area within the U.S. with a CDC Level 3 travel notice or similar State notice?
Yes
No
In the past 14 days, have you been in close contact with someone (family, friend, or coworker) who returned from any foreign country or an area within the US with a CDC Level 3 travel notice or similar State notice?
Yes
No
In the past 14 days, have you been in close contact (within six feet) of a person with a possible Coronavirus Infection?
Yes
No
In the past 14 days, have you tested positive for or been infected with Coronavirus (COVID-19)?
Yes
No
Do you currently have (or have you had in the past 14 days) any of the following symptoms: fever, bad cough, sore throat, runny nose, diarrhea, loss of smell/taste, shortness of breath, fatigue, vomiting or nausea.
Yes
No
I, undersigned, agree with the following statements:
As a precondition of receiving services, I have confirmed that my answers to this questionnaire are complete, true and accurate. I therefore consent to service rendered by this location on the terms and conditions.
I acknowledge and understand there is an increased risk that COVID-19 can be transmitted in any place of public accommodation. By entering the company premises and / or receiving services, I agree to assume these risks, and further agree that these risks are covered by the assumption of risk, release, waiver of liability, and indemnification provisions in the documentation I signed.
Upon arrival at the company, an employee can take my temperature with a contactless thermometer. If my temperature is 100.4F/38c or higher I will not be allowed to receive services. The service will be rescheduled for another time after I have been fever-free for at least 14 days.
In accordance with the guidelines, a mask must be worn during the service by me and the provider. I will bring a mask that is comfortable for me. I further agree to comply with the requirements throughout the service.
Date
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Month
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Day
Year
Date
Signature
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