Covid-19 Form

THE ONLY ONE IN THE WORLD!

Mirror House
COVID-19 FORM
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Mirror House > COVID-19 FORM

COVID-19 QUESTIONNAIR

Please complete the following questions by filling out ALL required fields BEFORE submitting

Have you, or anyone in your family, traveled in the past 14 days? *

Are you (or any one in your family) isolating or quarantining because you/they may have been exposed to a person(s) with COVID-19? *

Within the past 14 days, have you (or any one in your family) been in contact with Anyone with COVID-19 symptoms? *

Have you, or any one in your family, experienced any of the following symptoms in the past 48 hours : (please choose the following) *

Fever or Chills *

Yes

Coughs *

Yes

Shortness of breath or difficulty breathing *

Yes

Fatigue *

Yes

Muscle or body aches *

Yes

Headache *

Yes

Loss of taste or smell *

Yes

Sore throat *

Yes

Congestion or runny nose *

Yes

Nausea or vomiting *

Yes

Diarrhea *

Yes

Affirmation: I hereby testify that all the above information is true and will be held accountable in a court of law *

I do

Please let us know the date you wish to book your appointment (FRIDAY CLOSED!) *

Please select the time you wish to book (Please note that TOUR DURATION IS 2 HOURS) *

10:00 am

11:00 am

3:00 pm

4:00 pm (NOT AVAILABLE DURING RAMADAN)

5:00 pm (NOT AVAILABLE DURING RAMADAN)

Please advise number of visitors in your group MINIMUM 2 ADULTS (If you are a group of friends, each person MUST fill out the COVID-19 form and submit) *

Please advice if you are one family or a group of friends (IF YOU ARE MORE THAN ONE FAMILY EACH FAMILY MUST SUBMIT THEIR OWN COVID-19 FORM) *

Family

Friends

If you are a family, please advice if kids or teens are included: *

Yes

If kids or teens are included, please advice NUMBER of minors: *

Please advice the AGE of your child and/or teen: *

Please write your WhatsApp number INCLUDING COUNTRY CODE! *

Please write a local number in case we are unable to reach you by WhatsApp *

Please write your email address in case we are unable to reach you via WhatsApp *

Please write your name *

Notes

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Contact

The Mirror House

Qadisiya block 9, street 94, house 17
35809
Kuwait

+965-50747677 (WhatsApp ONLY!)

mirrorhouseq8@gmail.com

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