Visitor screening form

Visitor Screening

Issued: May 1, 2020

Name *

Loft you will be attending? *

Have you tested positive for Covid-19, or been in contact with someone who has in the past 14 days? *

Yes

No

Have you been tested for COVID-19 and are currently awaiting the test results? *

Yes

No

Do you have any of the following symptoms; fever, dry cough, body aches, headaches, sore throat, shortness of breath, loss of taste and/or smell, diarrhea? *

Yes

No

Are you in or your immediate contacts in a high-risk category? *

Yes

No

Have you travelled via a commercial airline or train (either internationally or domestically) within the last 14 days or failed to comply with applicable state mandated travel restrictions or quarantine orders? *

Yes

No

If you answer "YES" to any of the questions above, we respectfully ask you to postpone your visit, and inform your point of contact within Dermalogica.

If you answer "YES" to at least two questions, you are encouraged to seek mediical attention.

Thank you for your cooperation and understanding.

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