COVID-19 Screening Form | Exclusive Spa

First Name*

Last Name*

Phone Number*

Email Address*

Name of your service provider*

Who is your appointment with at Exclusive Spa?

Do you/they have a cough?*

Are you/they having shortness of breath or any other difficulties of breathing?*

Have you/they experienced recent loss of taste or smell?*

Any other flu-like symptoms, such as gastrointestinal upset headache or fatigue?*

Do you/they have a fever or have you/they felt hot or feverish recently within the last (14-21 days)?*

Are you/they over the age of 60 or are you living in an assisted living home?*

Have you traveled in the past (14-21 days) in any region affected by the COVID-19 or hot spots?*

I hereby understand the following:*