Client Medical Questionnaire

Form
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Date *

Month Day Year
Date
Client Health Questionnaire

Prior to the start of my service, I confirm that:
I have not been diagnosed with or cared for some one diagnosed with COVID-19 in the past two weeks *

False True
I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks (14 days) *

True False
I have not traveled outside of my immediate daily routine for the past two weeks (14 days) *

True False
I do not have a cough, fever, chills, shortness of breath, or loss of taste and smell *

True False
If I begin to show symptoms of COVID-19 with in the next two weeks (14 days) I will contact my stylist/the salon immediately. *

Yes No
I will follow all posted salon rules and regulations to keep myself, my stylist and all others around me safe. *

Yes No
Signature

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