Name: Ross Hair Studio & Clinic
Address: 1st Floor, Rathfarnham, Dublin 14, 54 Main Street, IE
Telephone: 01 492 5073

 01 492 5073 |  rosshairclinic@icloud.com |  Dublin 14

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COVID-19 QUESTIONNAIRE

Name*

Address/Eircode*

Mobile No*

Date of Appointment*

To ensure the safety and health of all people interacting with Ross Hair Studio and Clinic, clients and visitors must complete this declaration form prior to entering or on arrival at our salon. If you have been abroad in the previous 14 days of your appointment date, with exception to Northern Ireland, I will be unable to see you for the first week after you arrive home and you will need a negative Antigen test on the day of your appointment if it falls on the second week after you arrive home. If you have had Covid-19 or symptoms of Covid-19, I will require a negative PCR test 14 days after you showed signs of first symptoms.

Have you visited any of the countries outside Ireland excluding Northern Ireland in the last 14 days?*

Are you suffering from any flu-like symptoms?*

Are you experiencing any loss of taste?*

Have you developed a new and persistent cough?*

Are you experiencing any difficulty in breathing/shortness of breath?*

Are you experiencing any fever/temperature symptoms? *

Did you consult a doctor or medical practitioner? *

How are you feeling healthwise?*

Have you been in contact with someone who is confirmed to have COVID-19 or has visited an affected region in the past 14 days ?*

Message

NOTE: When in salon, please adhere to our in-salon standard processes/procedures regarding infection control, i.e., hand washing/hand sanitising and general
coughing/sneezing etiquette.

Contact Ross Hair Studio & Clinic Today to Book a Private and Confidential Hair Loss Consultation

01 492 5073 01 492 5073

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