Client Covid-19 Health Screen Questionnaire
This form must be completed and submitted before each appointment. It is intended for your safety and ours. Please answer all questions truthfully and as accurately as possible. Thank you for your understanding and cooperation. Health Screening Questionnaire Anyone showing symptoms of COVID-19 or who may have been exposed to COVID-19 should remain home, stay away from others, and contact their healthcare provider. Please contact PamperME to reschedule your appointment at www.441pamperme.com or email us at info@pamperme.com *Client must wear masks or face coverings during massage or esthetics treatments in accordance with regulations.
Name*
Phone #*
Email*
COVID Symptoms*
Please check the box if you have experienced ANY of the following symptoms within the last 14 days
Within the last 14 days, have you travelled outside of the country?*
Within the last 14 days have you come in close contact with anyone diagnosed with coronavirus (COVID-19) or has any health department or healthcare provider been in contact with you and advised you to quarantine?*