COVID-19 Precautionary Evaluation Form

Juniper&Poppy Salon 403 16th St Mall Suite 300 Denver, CO 80202

Juniper&Poppy Salon will be complying with ALL new state regulations implemented by DORA (Colorado Department of Regulatory Agencies) and following CDC guidelines.

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, Juniper&Poppy is taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please carefully read and complete the following form.

Symptoms of COVID-19, also known as Coronavirus, include but are not limited to:

-Fever

-Fatigue

-Dry cough

-Difficulty breathing

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Date

By checking the " I agree" boxes below, I agree that the following statements are true for myself:

I understand the above symptoms and affirm that I, as well as household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

I agreeI do not agree

I affirm that I, as well as household members, have not been diagnosed with COVID-19, within the last 30 days.

I agreeI do not agree

I affirm that I, as well as household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

I agreeI do not agree

I affirm that I, as well as household members, have not traveled outside of the country, or to a city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.

I agreeI do not agree

I understand that this business, Juniper&Poppy Salon, and it’s stylists, Layla Ogle and Michaela Drown, cannot be held liable to any exposure to COVID-19 or any other contagion caused by misinformation on this form or the health history provided by each client.

I agreeI do not agree

I affirm that should I, or any household members experience any of the above symptoms of COVID-19 before or on the day of appointment, I will cancel my appointment with Juniper&Poppy Salon immediately and acknowledge that there will be no fee associated with a short notice cancelation for this reason.

I agreeI do not agree

I knowingly and willingly consent to having a service with Juniper&Poppy Salon during the COVID-19 pandemic.

I agreeI do not agree

I understand that the CDC recommends social distancing of at least 6 feet and that is not possible with the nature of these services.

I agreeI do not agree

I have read and understand the new safety protocols published under the "COVID-19 Updates" section of our salon website, establishing how to safely receive a service at Juniper&Poppy Salon.

I agreeI do not agree

By signing below I agree to each statement above and release the business, Juniper&Poppy Salon and the stylists, Layla Ogle and Michaela Drown from any and all liability for the unintentional exposure or harm due to COVID-19, also known as Coronavirus.

Your stylist, Layla Ogle and Michaela Drown agrees and abides by these same standards and affirms the same. Juniper&Poppy Salon also affirms that improved and expanded sanitation protocols in accordance with the state of Colorado regulatory agency, DORA, are being implemented to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Signature

Precautionary Client Evaluation Form