Eyelash Extension COVID-19 Consent Form
Complete this form to confirm your health status and provide consent before receiving eyelash extension services.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Loss of taste or smell
None of the above
Have you been in close contact with anyone diagnosed with or suspected of having COVID-19 in the past 14 days?
*
Yes
No
Have you traveled outside your local area in the past 14 days?
*
Yes
No
Are you currently awaiting results from a COVID-19 test?
*
Yes
No
Do you agree to follow all salon safety protocols, including wearing a mask and rescheduling if you feel unwell?
*
Yes, I agree
No, I do not agree
Is there anything else you would like us to know regarding your health or recent activities?
Submit
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