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.