Disclaimer

BG Barbershop Covid-19 Questionnaire

The safety of our employees and customers is our main concern. Our business is taking extra precautions with the care of every client to include health review and enhanced sanitation/ disinfecting procedures in compliance with CDC guidance. We are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Self Declaration by Visitor:

1) Have you been diagnosed with Covid-19 or experienced any cold or flu-like
symptoms in the last 14 days (to include fever, cough, sore throat, respiratory
illness, difficulty breathing)?

YesNo

2) Have you had close contact with or cared for someones diagnosed with
COVID-19 within the last 14 days?

YesNo

3) Have you returned from any of the countries listed on Coronavirus FAQs within
the last 14 days?

YesNo

Electronic Signature

By typing your name in the box below, you are signing this Agreement electronically. You agree your electronic
signature is the legal equivalent of your manual/handwritten signature on this Agreement.