Covid Declaration form | karen-kaufman, caulfield, Victoria, Australia

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CLIENT DECLARATION FORM

I do not have a cough, cold or any flu like symptoms, including sore throat, hay fever, sinusitis, a post nasal drip, body aches or fever

True

False

I have not been tested or in contact with someone who is waiting for a COVID-19 test result in the past 14 days

True

False

I have not been overseas or in contact with anyone who has been overseas within the past 14 days prior to my appointment

True

False

I have not been in contact with anyone who has flu like symptoms within the last 14 days

True

False

I agree to a temperature check and to abide by all the health and hygiene protocols stipulated by Karen Kaufman Skin Care

True

False

I have had an Influenza vaccination this year

True

False

By submitting this form, I declare that the information I am providing is true to ensure the safety and protection of Karen Kaufman and other clients. I also declare that I have read and understand Karen Kaufman's COVID-19 safety plan, and I agree to be bound by its terms.

Thanks for submitting!

kskskin@gmail.com

133 Bambra Road
Caulfield, Victoria
Australia 3162

0418372359

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