COVID-19 Screening Questionnaire > Andrew Nuri | Best Hair Studio In Waterloo

COVID-19 Screening Questionnaire

I hope you are doing well and look forward to seeing you for your appointment.

The Ontario Ministry of Health has mandated that we ask you these questions before you come to our salon.

Summer Hours:
Mon-Fri : 10AM-6PM
Sat: 9AM-4PM

Appointment Date*
DD slash MM slash YYYY
Name*
First Last
Phone*
Email
Please Read All The Questions Before Answering
1- Did you have close contact with anyone with acute respiratory Illness?*
- No
- Yes
2- Did you travel outside of Ontario in the past 14 days?*
- No
- Yes
3- Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?*
- No
- Yes
4- Do you currently have any of the following symptoms:
Please put a checkmark on the symptoms you have, If you do not have any of the symptoms below, leave blank.
- Fever
- New onset of cough
- Worsening chronic cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Difficulty swallowing
- Decrease or loss of sense of taste or smell
- Chills
- Headaches
- Unexplained fatigue/malaise/muscle aches (myalgias)
- Nausea/vomiting, diarrhea, abdominal pain
- Pink eye (conjunctivitis)
- Runny nose/nasal congestion without other known cause
Consent*
I consent that all information provided in this form is true.