Covid-19 Screening Questionnaire

A. In the past 14 days have you
1. Had a high temperature (this means you feel hot to touch on your chest or back)?

Yes No

2. Had a new, continuous cough (this means you have been coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours - or if you usually have a cough, it has been worse than usual)?

Yes No

3. Had a loss or change to your sense of smell or taste (this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normal)?

Yes No

4. Had diarrhoea?

Yes No

5. Had more headaches than normal?

Yes No

6. Been in contact with anyone who was showing any of the above symptoms?

Yes No

7. Been tested positive for Covid-19?

Yes No

8. To the best of your knowledge, been in contact with anyone who has tested positive for Covid-19?

Yes No

9. Been to any areas (whether in the UK or abroad) where local lockdown measures are currently in place?

Yes No

B. Are you waiting for the results of a Covid-19 test?

Yes No

C. Are you occupying accommodation with anyone who is in quarantine?

Yes No

D. I confirm that I will comply with the Covid-19 precautions in place at the salon which include, but are not limited to, wearing a face covering and any PPE as requested by my therapist, washing my hands for at least 20 seconds after entering the salon and before my treatment commences, using the hand sanitiser provided before making payment.

Confirm Deny

E. I acknowledge that the Covd-19 virus has a long incubation period during which carriers of the virus may not show any symptoms but may still be highly contagious and that it is impossible to determine who has the virus and who does not given the current limits of testing

Acknowledge Deny

F. I acknowledge that due to the nature of the services provided at Beauty Be Mine, it is impossible to maintain social distancing measures and I accept that there may be an increased risk of contracting the virus.

Acknowledge Deny

G. I confirm that I give permission for the date and time of my visit to Beauty Be Mine and for my contact details to be released to the NHS Track and Trace service if appropriate.

Confirm Deny

H. I confirm that, if within the 14 days following my visit to Beauty Be Mine I test positive for Covid-19, I will immediately inform the salon.

Confirm Deny

I. I confirm that I understand a safety surcharge will be added to my treatment costs to cover the Covid-19 precautions which the salon has had to put in place.

Confirm Deny

J. I confirm that I wish to proceed with my treatment(s) and that I will not hold Beauty Be Mine responsible if I contract, or show symptoms of, Covid-19.

Confirm Deny

K. I confirm that Beauty Be Mine may keep my answers to this questionnaire for up to 21 days after the date of my appointment.

Confirm Deny

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