Full Name*

Address*

Mobile contact*

Are you currently experiencing or have experienced any of the following symptoms in the last 14 days?*

Is anyone in your household experiencing any symptoms of COVID-19 (as above)? If you have answered 'yes', we advise that you should self-isolate for 14 days.*

Yes No

Have you been in contact with anyone outside of your household who has been experiencing symptoms of COVID-19 in the last 7-14 days?*

Yes No

Have you returned from travelling abroad in the last 14 days?*

Yes No

If you have answered, yes, where and when?

Have you ever had a test for COVID-19*

Yes No

If yes, what was the outcome and if you had to self-isolate, please provide dates of self-isolation.

Please note that we are obliged to notify NHS Track and Trace if circumstances require such. If we report any symptoms among staff or clients, or are contacted by NHS Track and Trace, we are legally obliged to provide them with your contact details and you may be contacted. Please confirm you have read and understood this statement.*

Yes

If you or anyone in your household develops symptoms associated with COVID-19 within 7 days of your treatment, you must immediately contact us.*

Yes

Agreement: (you must agree to all the statements below, if you do not, please kindly contact us to reschedule your appointment)*

I have understood, read and completed this form truthfully to the best of my knowledge. I knowingly and willingly consent to having services at Station Nails and Beauty Ltd during the COVID-19 pandemic I consent for the service(s) to be carried out which involves a staff member of the Station Nails and Beauty Ltd team being in physical contact with me with less than 2 metres distance I confirm to the best of my knowledge that I, my household or social bubble have not been in contact with anyone that has had symptoms of COVID-19 in the last 14 days To prevent the spread of the virus and protect each other, I confirm that I will strictly follow the guidance provided at Station Nails and Beauty Ltd If guidelines are not strictly followed, I understand that Station Nails and Beauty Ltd has the right to cancel the appointment with the full cost of the service being charged and any other paid costs being non-refundable I confirm that I release the Station Nails and Beauty Ltd staff member performing the service and Station Nails and Beauty Ltd as a business from any and all liability for the unintentional exposure or harm due to COVID-19

I confirm that the information I have provided is truthful and to the best of my knowledge.*

Yes

If client is under 16 years old, please provide details of parent/guardian contact and parent to sign below.

Signature

Clear

Date of completion*

Month Day Year

COVID-19 Consultation Form