Pure Client COVID-19 Questionnaire

You must wear a mask and bring one to your appointment. Pure staff will be taking your temperature before your appointment starts. Please answer the following questions and sign. Please wash your hands after entering Pure Spa and after your service with the hand sanitizer provided.
1. Do you have any of the following COVID-19 symptoms now or within the past 7 days?*
Shortness of breath, Fever, chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat New loss of taste or smell, Vomiting, Diarrhea
- No
- Yes
Are any of these symptoms getting worse?
- No
- Yes
2. Have you tested positive for COVID-19 in the past 14 days?*
- No
- Yes
3. Have you been in close contact with someone recently diagnosed with COVID-19? (within the last 14 days)*
- No
- Yes
4. Have you traveled by plane in the past 7 days?*
- No
- Yes
When and where did you travel?
If you answered YES to any of these questions, you understand that you will be asked to reschedule. The safety of our clients and staff is the most important thing. We appreciate your understanding.*
I agree
Email
Your Name*
First Last
Your Signature*
Date*
MM slash DD slash YYYY

Δ