COVID-19 FORM

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Appointment Date

MM

DD

YYYY

Do you /have you had any symptoms of COVID-19 in the last 14 days? *

Persistent cough High temperature Loss of sense of smell/taste

Yes

No

Have you had any contact with anyone with symptoms/diagnosed with COVID -19 in the last 7 days? *

Yes

No

To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the studio’s strict guidelines *

By checking this box I acknowledge that I understand and accept the guidelines