Client Covid-19 Form Name * First Name Last Name Date * MM DD YYYY Are you currently experiencing one or more Covid like symptoms that are new or worsening? * Symptoms should not be chronic or related to other known causes or conditions. Yes No Has a doctor, healthcare provider, or public health unit told you that you should be isolating (staying at home)? * Either due to travel or contact tracing Yes No Have you been in close contact with a person who has flu like symptoms and is in isolation? * If fully vaccinated, select "NO" Yes No Has someone you live with tested positive for Covid-19 in the past 14 days? * Yes No Is anyone you live with currently experiencing any new Covid-19 symptoms and/or waiting for test results after experiencing symptoms? * If you are fully vaccinated, select "NO". If the individual experiencing symptoms received a COVID-19 Vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select "NO" Yes No I agree that I enter Waters Edge Salon & Spa of my own free will and do not hold them responsible if I come into contact with Covid-19 or it's variants. * Yes No I attest that the above is true to my knowledge and I take full responsibility to inform the owner if I develop any of the above symptoms during my time or come into contact with anyone testing positive for Covid-19 * Yes No If you answered "No" to all questions from 1 through 5, you may enter the salon and spa. In our building, everyone must continue to follow all public health and workplace control measures, including masking, maintaining physical distance and hand hygiene. Thank you!
