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Hair by Rivka
COVID-19 CLIENT QUESTIONAIRE
Due to the global pandemic of COVID-19, these questions must be answered by all clients within 24 hours of their service day/time.
COVID-19 Questionaire
Due to the global pandemic of COVID - 19, these questions must be answered by all clients within 24 hours of their service. If you have not filled out this form, you will be turned away.
First Name
Last Name
Email
Phone
Today's Date
Address
Have you or anyone in your home had any contact with any individual that has tested positive for COVID-19?
*
Yes
No
Are you or anyone in your house sick at this time?
*
Yes
No
Do you have a cough or runny nose?
*
Yes
No
Have you had a fever or shortness of breath?
*
Yes
No
Have you travelled domestically or internationally by commercial airline, bus, boat, or train in the last 14 days?
*
Yes
No
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?
*
Yes
No
By signing below, I understand that this is to provide the best guest experience and agree that neither Rivka Gluck nor Azura Studio will be held liable for any services rendered if I contract COVID-19.
Your Signature
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