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COVID-19 Screening Checklist For Clients

Purpose: Based on the US Center for disease Control Guidelines, service providers, daily are encouraged to screen all clients for signs of respiratory illness accompanied by fever.

Instructions: All clients entering Definition Beauty Spa must be asked the following questions below. We will maintain this record for 14 days from the completion of this form and have this form available upon request from the Public Health Department.

Name*

Date*

Time*

Temperature*

Do you have any of the following respiratory symptoms? - New Or Worsening Cough?*

Select an option

Do you have any of the following respiratory symptoms? - New or Worsening Shortness of breath?*

Select an option

Have you had a temperature of 100.4 F or greater within the last 14 days?*

Select an option

Have you been with person with confirmed COVID-19 by lab test within the last 14 days?*

Select an option

Have you traveled outside of the country within the past 14 days? *

Select an option

Have you come in contact with anyone reported to be, or expressing symptoms of the folowwing? *

Select an option

Have you recently participated in any gathering, meeting or had close contact with a large group of people?*

Select an option

I hereby authorize Defeinition of Beauty Spa to collect and process the data indicated herein for the purpose of contact tracing effecting control of the COVID-19 transmission.*

Select an option

If you answered NO to all questions you will be allowed to receive the services you have requested.

Please be aware of the following protocols:

• You will immediately wash your hands for at least 20 seconds upon arrival.

• Not to shake hands with, touch, or hugs others during your time in the building.

• Not congregate in any space within the spa. 

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