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Covid 19 Intake Questionnaire

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Covid 19 Intake questionnaire

Covid Intake questionnaire for beauty salon

Page 1

Please answer the following questions to help us ensure the safety of our staff and clients.

Email*

Full Name*

Phone Number*

Date of Birth*

Select date

Gender*

Ethnicity*

Race*

Employment Status*

Marital Status*

10.

Living Situation*

11.

Household Income*

Description:This Covid intake questionnaire is designed for beauty salons to ensure the safety of their clients and staff. It includes questions related to Covid-19 symptoms, travel history, and exposure to infected individuals. By filling out this form, clients can help the salon take necessary precautions to prevent the spread of the virus.

During the Covid-19 pandemic, it is crucial for businesses to take necessary precautions to ensure the safety of their clients and staff. Beauty salons are no exception. This Covid intake questionnaire is specifically designed for beauty salons to gather information about their clients' health and travel history to prevent the spread of the virus. The form includes questions related to Covid-19 symptoms, recent travel, and exposure to infected individuals. By filling out this form, clients can help the salon take necessary precautions to prevent the spread of the virus. This questionnaire is an essential tool for beauty salons to maintain a safe and healthy environment for their clients and staff.

Full Name*

Phone Number*

Address*

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Full Name*

Phone Number*

Address*

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Date of Birth*

Select date

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What is your last name?*

What is your date of birth?*

Select date

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Full Name*

Address*

Phone Number*

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Introduction*

Consent*

I have read and understand the information provided.

I have had the opportunity to ask questions and have had them answered to my satisfaction.

I consent to participate in telehealth services.

Patient Name*

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What is your age?*

What is your gender?*

How long have you had tinnitus?*

Less than 3 months

3-6 months

6-12 months

More than 1 year

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Full Name*

Date of Birth*

Phone Number*

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