Health Declaration Form | MicheleRoseBeauty

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms such as; cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. As well as all household members, do not currently have. (With in the last 14 days.)

I haven’t been in close contact with a Covid-19 patient in the last 14 days. I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 30-days.

Initials

Date

I understand that Michele Rose Beauty, cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. With initials above, I agree to each statement above and release Michele Rose Beauty from any and all liability for unintentional exposure or harm due to COVID-19.

Thanks for submitting!