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The Mirror House
THE ONLY ONE IN THE WORLD!
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COVID-19 FORM
COVID-19 QUESTIONNAIR
Please complete the following questions
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
No
Coughs *:
Yes
No
Shortness of breath or difficulty breathing *:
Yes
No
Fatigue *:
Yes
No
Muscle or body aches *:
Yes
No
Headache *:
Yes
No
Loss of taste or smell *:
Yes
No
Sore throat *:
Yes
No
Congestion or runny nose *:
Yes
No
Nausea or vomiting *:
Yes
No
Diarrhea *:
Yes
No
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 :
10:00 am
11:00 am
3:00 pm
4:00 pm
5:00 pm
Please advise number of visitors in your group (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 *:
Family
Friends
If you are a family, please advice if kids or teens are included: *:
Yes
No
If kids or teens are included, please advice NUMBER and AGE: *:
Please write your WhatsApp number *:
Please write your name *:
Notes *:
Please copy this text: 888d9d48b3ee
Contact
The Mirror House
Qadisiya block 9, street 94, house 17
35809
Kuwait
+965-50747677 (WhatsApp ONLY!)
mirrorhouseq8@gmail.com
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COVID-19 FORM
