Covid-19

COVID-19 Screening Questionnaire

* Indicates required field

Name *

First

Last

Phone Number *

Current Temperature reading. *

In the past 30 days, have you or someone you live with been diagnosed with COVID-19? *

No Yes

THE SYMPTOMS WE'RE MOST CONCERNED ABOUT ANY OF THE FOLLOWING

Fever or chills (>37 cELCIUS DEGREE)
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

In the past 14 days, do you have any of the following symptoms? Choose One *

No Yes

In the past 14 days, have you returned from travel outside of the US? *

No Yes

In the past 14 days, have you been unprotected close contact with someone diagnosed with COVID-19 (Close contact means within 6 feet for more than 15 minutes) *

No Yes

By clicking submit button below, you attest that the answers you've provided are true and complete and understand that providing accurate information regarding symptoms and exposures during the pandemic is critical to your safety as well as the safety of our patrons and employees

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Touch of Beauty, LLC of San Mateo (“TOBs”) has put in place preventative measures to reduce the spread of COVID-19; however, TOBs cannot guarantee that you will not become infected with COVID-19. Further, patronizing TOBs may expose you to higher risk of contracting COVID-19.
By clicking submit, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk and that such exposure or infection may result in personal injury, illness, permanent disability, and death. You understand that the risk of becoming exposed to or infected by COVID-19 at TOBs may result from the actions, omissions, or negligence of ourselves and others, including, but not limited to, TOBs employees and clients. You voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that you may experience. You hereby release, covenant not to sue, discharge, and hold harmless TOBs, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. You understand and agree that this release includes any Claims based on the actions, omissions, or negligence of TOBs, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after patronizing services at TOBs.

Submit

COVID-19 Screening Questionnaire

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