Day-Of Appointment Wellness Screenings

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COVID-19 wellness screening

This form must be completed and submitted prior to each appointment. It is intended for your safety and ours. Please answer all questions truthfully and as accurately as possible. Thank you for your understanding and cooperation.

Anyone showing symptoms of COVID-19 or who may have been exposed to COVID-19 should remain home, stay away from others, and contact their healthcare provider. Please contact us to reschedule your appointment at (949) 288-3341 or divineandshadow@gmail.com

Client Name

Appointment Date

Have you experienced any of the following symptoms within the last 14 days?

Fever

Chills

Shortness of breath or difficulty breathing

New cough

New loss of taste or smell

New rashes or lesions

Nausea or vomiting

Diarrhea

Within the last 14 days have you tested positive for COVID-19, come in close contact with anyone diagnosed with COVID-19, or has any heath department or healthcare provider advised you to quarantine? *

Yes

Within the last 14 days, have you traveled outside of the country? *

Yes

Your Signature