Wellness Screening Name First Last Phone*Date MM slash DD slash YYYY Email Have you experienced any of the symptoms within the last 14 days?1. A new cough?* Yes No 2. Feeling feverish or have a fever?* Yes No 3. Have or had shortness of breath?* Yes No 4. Have you had a loss of smell or taste?* Yes No 5. Have you been in close contact with anyone with these symptoms?* Yes No 6. Have you been in close contact with anyone who has been diagnosed with COVID-19 in the past 14 days?* Yes No If you answered YES to any of the above, please describe: When you arrive for your appointment, text me from your car and I will come to the front door to let you in the building. If you have a temperature, services cannot be provided You will wash/sanitize hands You will be wearing a mask during the procedure. We will keep talking to a minimum during the procedure to minimize potential spread Bring exact change for cash Bring minimal personal belongings to your appointment. I can only accommodate 1 client at time. I’m looking forward to working with you. See you soon.EmailThis field is for validation purposes and should be left unchanged.
