Coronavirus Intake form for Massage Therapists

Lashes For Days Salon Screening for COVID-19

For all of our safety, please fill this out 24 hours prior to each appointment (until further notice). If you answer YES to any of the questions below, your appointment may be postponed. If any changes occur after completing this form, please notify Lashes For Days as soon as possible. Please note that proof of full vaccination is required while in Level 2. Thank you!
Today's Date

MonthDayYear
Date
Your Appointment Date

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Mobile Phone Number*

Area CodePhone Number
Do you have any of the following symptoms: fever above 38°C, new or worsening chronic cough, sore throat, runny nose, headache, new onset fatigue, new onset muscle pain, diarrhea, loss of taste, loss of smell? Note: If you usually have a symptom because of allergies etc, don’t count that as a symptom unless it is worsening.

YesNo
Have you recently had a positive PCR or Rapid Test or waiting for test results (and have symptoms)?

YesNo
Are you or anyone in your household currently isolating?

YesNo
Have you recently been a close contact to someone who has tested positive for covid?

YesNo
Your help is needed to help reduce the spread of the virus.

What will be required from you:
-Please bring and wear your own face covering to your appointment.
-Please only bring yourself and your essentials only (phone, keys, wallet).
-It is recommended to dress in layers if you get cold easily as bedding will be minimized.
-Wash your hands before and after your appointment by either washing them in the client bathroom or using the provided hand sanitizer.
-Remain in your car until it is your appointment time to reduce traffic at the entrance.
- Before entering, you will be asked if anything has changed since filling out this form. If you are showing visible symptoms, we reserve the right to cancel your appointment.
-Opt for non-contact payment options such as debit, credit or e-transfer (e-transfer is preferred).
-Please be patient as we all adapt to our new "normal".

New standards are in place to help prevent the spread of COVID-19. If somehow you do contract the virus, you release all liability from Lashes For Days and the salon owner. By signing this form, you agree with this statement.
Signature

Clear
Should be Empty:

Lashes For Days Salon Screening for COVID-19