Golden NailsbCovid-19 Service Agreement Form

Take Photo Before Treatment*

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Postal Code

Date of Birth

Date

Email*

example@example.com

Phone Number*

Area CodePhone Number

Name of Therapist

Name of GP

Temperature Reading*

Have you a high temperature (more than 37.9c)?*

YesNo

Do you have any kind of cough?*

YesNo

Do you have any breathing difficulties or shortness of breath?*

YesNo

Have you lost your sense of smell or has your sense of smell changed?*

YesNo

Have you in the last 14-days been in an area with known risk of imported cases or travelled by plane, bus, train, tram etc?*

YesNo

Have you been in close contact in the last 14-days with a person who has Covid-19?*

YesNo

Do you have any health conditions?*

YesNo

Please specify

Face treatment

Nail Treatment Type?

Pedicure Treatment Type?

Type of Waxing?

INFORMED CONSENT TO SERVICE.

I have been fully informed of the high risks of the service including, but not limited to infection, scarring, melanomas, alergic reaction to the service, I have been fully informed of the pontential risks associated with getting the service at the salon.

I still wish to proceed with the service and I assume all risks that may arise. I will inform the therapist of any discomfort that I may experience during my treatment to allow the therapist to adjust accordingly.

I certify that I have checked and confirm that the information provided above is correct and will inform the salon of any changes that may arise.

During the Covid-19 pandemic, I understand that I may get infected at the salon. I agree not to sue and to waive all liabilities against my therapist or their employer for anything that may happen to me during or after my treatment.

Signature*

Date*

Date

If under 16 years Parent/Guardian Signature.