Covid - 19 Form

Temperature Checking
Temperature Checking
Washing Hands
Washing Hands
Hand Sanitizer
Hand Sanitizer



Q1. Do you have any symptoms of Fever, Cough, Sore throat and /or fatigue anytime during last 21 days ?
Ans. YesNo

Q2. Did you experience any difficulty in breathing anytime during last 21 days ?
Ans. YesNo

Q3. Do you have any exposure to a known or suspected case of Covid-19 patient in last 21 days ?
Ans. YesNo

Q4. Have you visited any other medical facility /hospital in last 21 days ? If yes, for what reason ?
Ans. YesNo

Q5. Are you residing in a locality that has been notified by the government as a covid containment zone in last 21 days?
Ans. YesNo

Q6. Have you ever been tested for Covid-19 ? If yes, give details
Ans. YesNo

Q7. Have you downloaded the Aarogya setu app
Ans. YesNo

The above information given by me is true to the best of my knowledge . I fully understand and acknowledge that withholding or mis-representation of any information is highly unethical and against the interest of larger population during this pandemic.

I have been made aware that services create ultra-fine spray that may transmit the Covid-19 virus. I understand the Covid-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I also understand that, due to the contagious nature of the disease and characteristics of the procedures, I have an increased risk of contacting the virus simply by being in a salon or taking services at home.

I fully understand and acknowledge that I may be an asymptomatic carrier of the disease and hence will strictly comply with all safety precautions and protocols advised . In the eventuality of my testing covid positive at a later date , I will not hold the Salon service provider/staff/set-up responsible for it .. I hereby knowingly and willingly give consent to have my procedure completed during the Covid pandemic.

Client Consent
I agree

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