Covid-19 Questionnaire

1 Shannon Court Unit 103
Bristol, Rhode Island 02809
401.254.2648

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COVID-19 Questionnaire

Please note, all persons entering A Moment In Time Photography for a photo session must submit a COVID-19 questionnaire no later than 4 hours and no sooner than 24 hours before your scheduled photo session.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Have you, anyone in your household, or anyone attending your photo session experienced any of the following symptoms in the last 48 hours? Fever, cough, shortness of breath or difficulty breathing, body aches, chills, runny or stuffy nose, sore throat, diarrhea, loss/reduced send of smell or taste, or nausea and vomiting? *

Yes No

Have you, anyone in your household, or anyone attending your photo session tested positive for COVID-19 in the last 14 days? *

Yes No

Are you, anyone in your household, or anyone attending your photo session currently waiting on the results of a COVID-19 test? *

Yes No

Have you, anyone in your household, or anyone attending your photo session been around any person that has tested positive for COVID-19, or have been put on quarantine by the RIDOH or Mass DPH in the last 14 days? *

Yes No

If you, anyone in your household, or anyone attending your photo session was exposed, has that individual taken a COVID-19 test with a negative result? *

Yes No N/A

Have you, anyone in your household, or anyone attending your photo session travelled anywhere outside of the 50 United States, or on a cruise in the last 14 days? *

Yes No

Have you, anyone in your household, or anyone attending your photo session travelled anywhere in the United States by commercial airlines or by any other mode of transportation in the past 14 days? Please refer to new returning to Rhode Island guidelines about being tested or quarantining. *

Yes No

I understand that A Moment In Time Photography is following all RIDOH & CDC regulations and guidelines and will not hold them liable for any COVID-19 related illness or complications. *

I attest

Submit