Name
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First Name
Last Name
Phone
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Country
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Email
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Today's Date
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MM
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I affirm that I have not experienced any combination of the following symptoms within the last 14 days, nor have any of my household members: Dry cough, shortness of breath/ difficulty breathing, fever, fatigue, chills, severe headache, body aches, sore throat, loss of taste or smell, loss of appetite, or nausea. I agree not to enter the studio if I am experiencing any of these symptoms.
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I affirm that I, as well as all household members, have not been diagnosed with Covid-19 within the last 30 days.
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I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with Covid-19 within the last 30 days.
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In-Studio Temperature Check: I’m willing to take a contact-free forehead temperature check upon entry to the studio.
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I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I will ensure my session is scheduled at least 10 days after any air travel.
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I verify that I have not traveled outside the United States In the past 10 days.
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I confirm that I have not traveled domestically within the United States by commercial airline, bus or train within the past 10 days.
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A mask, gloves, shoe coverings and hand sanitizer will be provided during the session per my request.
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I understand that in order to keep the number of people within the studio to a minimum, only clients who are being photographed and one guardian will be allowed to enter at this time.
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I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when visiting Dauss Miller | Photographer Studios.
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