Salon Health Screening and COVID-19 Consent Form
Please complete this form before your salon appointment to help us ensure a safe environment for all clients and staff.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Appointment Date
*
-
Month
-
Day
Year
Date
Have you experienced any of the following symptoms in the past 14 days? (Fever, cough, shortness of breath, loss of taste or smell, sore throat, chills, muscle aches, or headache)
*
Yes
No
In the past 14 days, have you been in close contact with anyone diagnosed with COVID-19?
*
Yes
No
Have you traveled internationally or to any COVID-19 hotspot in the last 14 days?
*
Yes
No
Have you received a COVID-19 vaccination?
Yes
No
Prefer not to say
I acknowledge and agree to follow the salon’s health and safety protocols during my visit.
*
I agree
By submitting this form, I confirm that the information provided is accurate and I consent to receive salon services today.
*
Submit
Submit
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