COVID19: Client Screening - 717 Tattoo & Body Piercing

COVID19: Client Screening - 717 Tattoo & Body Piercing

Client Health Pre-Screening
Your Name *

First Name Last Name
Your Email
Phone Number *

Area Code Phone Number
My procedure will be completed today at the follow 717 Tattoo location: *
Neither I nor anyone in my household have experienced COVID19 symptoms within the last 30 days *

This statement is true
I have taken my temperature within the last 4 hours, and it was below 100 degrees F

This statement is true
Have you been to any large events, or traveled within the last 30 days? *

No I have not
Are you aware that a procedure at 717 Tattoo & Body Piercing may result in a weakened immune system during the healing process? *

Yes I am
Do you have any condition that would prevent you from wearing a mask while in the studio? *

Yes I do No I do not
Do you agree to adhere to physical distancing and hand washing protocol while in the studio? *

Yes I do
Are you willing to be seen for your procedure?

Yes I am
By submitting this form, I attest the above information is true to the best of my knowledge. The 717 Tattoo & Body Piercing studio COVID19 protocol practices have been fully explained to me. I was afforded the opportunity to ask any questions I may have regarding risks due to the pandemic, & All questions were answered to my satisfaction. I fully understand the exposure risks I may face during my visit to the studio, & agree to hold 717 Tattoo & it's affliates free of any harm as a result of my patronage. I understand my information will be kept confidential & that I may received marketing information from 717 Tattoo. I have read, reviewed, understand, & agree to the 717 Tattoo Client Policy online here: https://717tattoo.com/covid19
Today's date *

Month Day Year
Date
Signature *

Clear
Should be Empty: