Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date
*
-
Month
-
Day
Year
Date
Client Health Questionnaire
Prior to the start of my service, I confirm that:
I have not been diagnosed with or cared for some one diagnosed with COVID-19 in the past two weeks
*
False
True
I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks (14 days)
*
True
False
I have not traveled outside of my immediate daily routine for the past two weeks (14 days)
*
True
False
I do not have a cough, fever, chills, shortness of breath, or loss of taste and smell
*
True
False
If I begin to show symptoms of COVID-19 with in the next two weeks (14 days) I will contact my stylist/the salon immediately.
*
Yes
No
I will follow all posted salon rules and regulations to keep myself, my stylist and all others around me safe.
*
Yes
No
Signature
Submit
Should be Empty: