Appointment Date

Your Name

Beauty Technician

Have you travelled out of the state in the last 14 days?

If yes, where did you travel to?

In the past 14 days have you had contact with a person who has COVID-19, tested postive for COVID-19, or have traveled to high-risk regions?

In the past 14 days have you or anyone in your household had flu-like symptoms, body aches, chills, cough, shortness of breath, or fever? *

Do you have a fever or are you experiencing body aches or chills?

Do you have respiratory symptoms such as cough or shortness of breath? *

Acceptance

I have answered these questions truthfully. After assessing the degree of risk associated with getting my service completed at this time and the precautionary measures in place, I hereby release my provider from any liability by the broadest release allowed by law. I understand that if at any time I feel uncomfortable proceeding with my appointment for any reason, or if my health or risk of exposure changes, it is my responsibility to notify my stylist immediately and reschedule my appointment.

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