Intake Form
Date:
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Month
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Day
Year
Date
First/Last Name:
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First Name
Last Name
COVID-19 Screening Questionnaire
During the last 10 days have:
1. You tested positive for COVID-19
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Yes
No
Test Date:
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Month
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Day
Year
Date
Test Result
Positive
Negative
Pending
2. You come into contact with someone who tested positive for COVID-19
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Yes
No
Contact Date:
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Month
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Day
Year
Date
3. You or someone in your household been asked to be quarantined in the last 10 days
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Yes
No
Starting Date:
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Month
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Day
Year
Date
Ending Date:
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Month
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Day
Year
Date
4. You been sick or experienced any cold or flu like symptoms
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Yes
No
5. You had a fever greater than 100.4 Degrees Fahrenheit
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Yes
No
6. You had a cough/shortness of breath/trouble breathing
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Yes
No
7. You traveled out of the country
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Yes
No
ACKNOWLEDGMENT I have carefully read Simply Skin Las Vegas’s Covid-19 Questionnaire, and hereby attest that the above questions are answered correctly. I, the undersigned patient consents to an in-person consultation and/or to have my Provider and/or his/her staff perform procedures on me, whether regarded as elective or aesthetic during the time of the COVID-19 pandemic and after. I understand in person consultations and/or treatments currently despite my own best efforts or the Providers that I have an elevated risk for COVID-19 and consent to Consultation(s) and/or Treatment(s).
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Client/Guardian Signature
If minor, Parent/Guardian Signature
Please hand the iPad to a Staff Member
Front Desk Signature
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Submit
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