COVID-19 Medical Questionnaire

Please fill out the following form before your service.

First Name

Last Name

Email Address

Date of Birth

Are you currently experiencing a cough, shortness of breath, fever, sore throat, diarrhea, or any other cold or flu like symptoms?

No

Yes

Have you been in contact with anyone who has know symptoms of COVID-19 positive, or are you waiting on the results of a COVID-19 test?

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!