• Coronavirus-19 Health Declaration Form

    Coronavirus-19 Health Declaration Form

    For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.

  • Personal Information

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  • Date of Visit*
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  • Your Hairstylist*

  • Travel and Health Declaration

  • 1) Have you travelled to and from any country(ies) within the last 14 days?*
  • 2) Are you currently serving Quarantine Order (QO) / Leave of Absence (LOA) / Stay-home Notice (SHN)?
  • 3) Have you been in contact with any COVID-19 confirmed infected/diagnosed or suspected person(s), or any person(s) under Quarantine Order (QO) / Leave of Absence (LOA) / Stay-home Notice (SHN)?
  • Rows
  • 5) Are you working from home now?

  • I acknowledge that the information I've given is accurate and complete.

    # Under the Infectious Diseases Act, it is an offense to provide FALSE information in the health declaration form.

  • By submitting this form, you agree to provide your personal data and understand that the data gathering is solely for contact tracing should the need arise.

  • Date
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  • Clear
  • Should be Empty: