COVID-19 Intake Form

I confirm that I am NOT presenting ANY of the following symptoms:

• Cough
• Shortness of breath or difficulty breathing
• Fever
• Sore throat
• Muscle or body aches
• Congestion or runny nose
• Nausea
• Diarrhea
• New loss of taste or smell

I confirm that I have not in the past 14 days:

• Traveled internationally
• Tested positive for COVID-19
• Been advised to quarantine
• Been in close contact with someone who has COVID-19

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and may be contagious. I understand that due to the frequency of the visits of other clients and the characteristics of the virus, I have an elevated risk of contracting the virus simply by being in a salon.

Should my service provider find that I may be exhibiting symptoms of illness, I understand they have the right to reschedule my service at a later date.