COVID-19 Health Declaration Form

A pre-visit health declaration that salons use to screen clients for travel history, quarantine status, and possible COVID-19 exposure before their appointment.

Use this template

Full Name

Nombre

Apellido

NRIC/FIN/Passport Number (last 4 digits)

Mobile No. (Local / Overseas)

Email

Date of Visit

Your Hairstylist

Stylist 1 Stylist 2 Stylist 3 Other

1) Have you travelled to and from any country(ies) within the last 14 days?

Yes No

1a) If the answer is "yes" for question #1, please state the country(ies) you had visited

1b) If the answer is "yes" for question #1, please state the date(s) of your visiting

2) Are you currently serving Quarantine Order (QO) / Leave of Absence (LOA) / Stay-home Notice (SHN)?

Quarantine Order (QO) Leave of Absence (LOA) Stay-Home Notice (SHN) None of the above

3) Have you been in contact with any COVID-19 confirmed infected/diagnosed or suspected person(s), or any person(s) under Quarantine Order (QO) / Leave of Absence (LOA) / Stay-home Notice (SHN)?

Yes No

3a) If the answer is "yes", please tell us your relationship with the people and your last contact date with them

5) Are you working from home now?

Yes No

Department

Additional Remarks

Date

Signature

Sign here

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COVID-19 Health Declaration Form

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