Covid-19 Questionnaire

Covid-19 Self Assessment Form

To ensure the Safety & Health of all people interacting with Ravens Hair Salon, Clients must complete this declaration form prior to entering our Salon. If you indicate to us you have symptoms of COVID-19 OR you have been abroad in the last 14 days with exception to Northern Ireland you should not visit our Salon. We advise you to seek professional medical help/assistance.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number

Health Declaration Form

Due to the close contact nature of our business, we are requiring all salon visitors to complete a self-declaration form. This form is completely confidential and enables our business to mitigate the risk of a novel Coronavirus disease (COVID-19) outbreak in our salon.
I hereby certify that

I HAVE NOT Tested Positive for COVID-19
I hereby certify that

I HAVE NOT Been identified as a potential carrier of any "Coronavirus"
I hereby certify that

I HAVE NOT Experienced symptoms commonly associated with Coronavirus
I hereby certify that

I HAVE NOT Been in direct contact with any person considered to be in a high-risk category for contracting Coronavirus or who has contracted Coronavirus
I hereby certify that

I CAN account for all locations visited during the cocooning phase in Ireland
Are you considered to be in the COVID19 'high risk' category based on age and/or medical grounds? *

Yes No
I hereby certify that

I WILL if asked, wear a mask at all times during my visit
Private Data Protection Notice:
This data sheet will be stored confidentially and is not shared with any third party, unless there will be an official request by the local authorities for reasons of public interest in the area of public health. The datasheet will be deleted one month after collection, unless a longer period is required by the public authorities.

Thank you for your cooperation!
Signature *

Clear
Should be Empty:

Covid-19 Self Assessment Form