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COVID Client Pre-Screening Form
If you are scheduled for a consultation/estimate, you must complete this
pre-screening form.
First Name
Last Name
Email
Have you or any member of your household/property tested postive or a "detected" test for COVID-19 infection within the past ten (10) days?
No
Yes
Have you or any member of your household/property developed ANY of the following symptoms of COVID-19 infection in the last ten (10) days: (Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, unusual headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomitting, diarrhea?)
No
Yes
Within the last ten (10) days, have you or a member of your household/property been in contact with someone who tested positive or "detected" results from a COVID-19 test?
No
Yes
Date
Initials
I confirm that the information given in this form is true and my initials and submission confirms my signature of this valid information.
Submit
Your form as been submitted!
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