COVID Questionnaire

Hello, lovely clients! Because I am at a relatively high risk of covid complications, before we can proceed with rescheduling, I need you to fill out this form. Please be honest! I am also more than happy to provide you with any information about my own personal social distancing practices to help you feel more comfortable.

I promise I will honor all deposits, gift certificates, and appointments as quickly as I am safely able. If you do not want to disclose this information, I totally understand, but will be unable to book you at this time.

* Indicates required field

Name (Please write your first & last name in the "first name" box and your email address in the "last name" box! This site won't let me have more than five fields.) *

First

Last

Have you (check all that apply): *

Flown on an airplane recently Visited a hospital Had contact with a person who tested positive for COVID None of the above

Please indicate whether your appointment was canceled due to COVID, you were on a waitlist, or you purchased a gift certificate around the holidays. Additionally, what is your occupation? If it puts you at any legal risk to disclose your occupation, please disregard that part of the question! *

What is your level of occupational exposure? *

None (working from home entirely/unemployed) Some exposure (to coworkers, but not to the public) Moderate exposure (customer service, but not a high-risk population) High exposure (working in medical field or field that requires direct contact)

Describe your social distancing practices & risk tolerance! For example, I am not going to public places (such as restaurants, bars, or stores) except for necessities (groceries etc), I only see friends outdoors & always masked if at less than 6ft (mostly masked even when further apart), and am limiting my social interactions drastically even in these contexts. *

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