Have you been diagnosed with confirmed or suspected Covid-19 infection in the last 14 days? *

Yes

No

Have you had any contact with an individual who has been diagnosed with Covid-19? *

Yes

No

Do you have any of the following symptoms? *

A temperature above 37C

Any kind of cough

Difficulty breathing

Change in sense of smell or taste in the past 14 days

None of the above

Have you been abroad traveling, near large groups or have you not been socially distancing at any point in the past 14 days? *

Yes

No

Do you agree with the following? *

I understand the above symptoms and affirm that I, as well as all members of my household, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all members of my household, have not been diagnosed with Covid-19 within the last 30 days. I affirm that I, as well as all members of my household, have not knowingly been exposed to anyone diagnosed with Covid-19 within the last 14 days. I affirm that I, as well as all household members, have not travelled outside the country or to any city outside of our own that is or has been considered a ‘Hot Spot’ for Covid-19 infections within the last 30 days. I understand that this business cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. By signing below I agree to each above statement and release Noeleen Cunningham and the business from any and all liability for the unintentional exposure or harm due to Covid-19 I agree to abide by these same standards and affirm the same.

Yes I agree

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY