Covid-19 Form

Contact

The Mirror House

mirrorhouseq8@gmail.com

Qadisiya block 9, street 94, house 17
35809
Kuwait

+965-50747677 (WhatsApp ONLY!)

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 (Please note that TOUR DURATION IS 2 HOURS) *	10:00 am 11:00 am 3:00 pm 4:00 pm 5:00 pm
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 No
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 *
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

COVID-19 QUESTIONNAIR

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