Client Name
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First Name
Last Name
Cell Phone:
*
Email:
*
example@example.com
Service provider that you will see first.
*
Are you aware of being exposed to COVID-19?
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Yes
No
Have you been in contact with anyone with symptoms?
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Yes
No
Have you tested positive for COVID-19?
*
Yes
No
Please initial here confirming you will allow us to take your temperature before entering the building. You will also wear a mask at all times. If you have any medical conditions that prevent you from wearing a mask, you will inform us, and in that case, we will set-up a private room service for you to receive services, in a safe manner.
*
You will indemnify and hold harmless A Moment's Peace Salon & Day Spa and all of its employees for any and all responsibility and claims as it pertains to any virus infections as well as COVID-19 related incidents while receiving services. You are aware of the risks and will do your part to keep everyone safe.
By entering your name in the signature field, you agree your electronic signature is the legal equivalent of your manual signature on this form.
Signature
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Clear
Date
*
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Month
-
Day
Year
Date
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