Chava' Pelo Salon Self-Assessment Form

Full Name

First NameLast Name

E-mail

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you traveled to any known region with COVID-19 in the last 14 days?*

YESNO

Do you have a fever or have you felt feverish in the last 14-21 days? (38*C or 100.4*F)*

YESNO

Are you having shortness of breath or other difficulties breathing?*

YESNO

Do you have a cough?*

YESNO

Any other flu - like symptoms such as, gastrointestinal upset, headache or fatigue?*

YESNO

Have you experienced recent loss of taste or smell? *

YESNO

Are you in contact with any known COVID-19 positive patient? *Guests who are well but have a sick family member at home with COVID-19 should postpone services.*

YESNO

Have you tested positive for COVID-19 or presumed positive based on your health care providers assessments or your symptoms within the last 14 days? *

YESNO

Please share your most recent COVID-19 Test date. Please note date in the other box.*

I have not been testedI have been testedOther

Please share your most recent COVID-19 test result.*

PositiveNegativeI have not been tested

COVID-19 Liability Waiver

I acknowledge the contagious nature of Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Chava' Pelo Salon , Bobbie Chavarria, has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Chava' Pelo Salon, Bobbie Chavarria, cannot guarantee that I will not become infected with Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon team members, and other salon guests and their families.

I voluntarily seek services provided by Chava' Pelo Salon, Bobbie Chavarria and acknowledge that I am increasing my risk to exposure to Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I hereby release and agree to hold Chava' Pelo Salon, Bobbie Chavarria harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Chava' Pelo Salon, Bobbie Chavarria. I understand that this release discharges Chava' Pelo Salon, Bobbie Chavarria from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Chava' Pelo Salon, Bobbie Chavarria. This liability wavier and release extends to the salon together with all owners, partners, and team members.

Signature*

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