Health Self-Screening Form
This form is part of the COVID-19 Addendum to the Terms of Service. Please complete and submit 24 hours prior to your appointment. If you respond "yes" to any of the following questions, reschedule your appointment immediately for at least weeks out.
Last Name
Email
Phone Number
Have you been vaccinated for COVID-19? (You will be asked to show vaccination card at appointment.)
Yes
No
Do you have a temperature higher than 100.3 degrees Fahrenheit? (Your temperature will be checked prior to starting the appointment.)
Yes
No
Have you been in close contact with anyone who has been ill or tested positive for COVID-19 in the past two weeks?
Yes
No
Have you experienced or are experiencing any fever, cough or flu-like symptoms in the last two weeks?
Yes
No
Have you traveled outside of the U.S. in the last two weeks?
Yes
No
If you answered "Yes" to the previous question, please include all of the locations traveled (city, state and country).
Safety Protocol. (Please check each box as confirmation that you have read and understood.)
Wear a face covering, unless mutually agreed to remove it
Maintain a reasonable distance from one another, as much as possible
Wash/sanitize hands frequently
Cover sneezes and coughs with face covering or tissue
Handshakes and unnecessary physical contact are prohibited
Other safety consideration. (Please check each box as confirmation that you have read and understood.)
No other person, other than Client and Consultant, may be in the room during the consultation.
Maximize room air exchange by opening all windows and doors.
Government requirements regarding COVID-19 (Please check each box as confirmation that you have read and understood.)
Agree to follow all health orders, laws and requirements by local, state and federal governments
These requirements dictate how to conduct business during the Pandemic
These requirements may be updated at any time, without notice
Terms of Service and COVID-19 Addendum (Please check each box as confirmation that you have read and understood.)
You agree to read the Terms of Services
You agree to read the COVID-19 Addendum
These documents are found on TheClosetEditCo website
Your Signature
*
Clear
Date
Submit