COVID-19 Consent To Perform Services or Treatments

COVID-19 Consent To Perform Services or Treatments
Name *

First Name Last Name
Date *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I knowingly and willingly consent to have salon/ spa service(s) during the COVID-19 pandemic at Simply Be Beautiful. *

I have read and agree with the statement above.
I understand the COVID-19 virus has a long incubation period during which carries of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing. *

I have read and agree with the statement above.
I understand that due to the frequency of visits of other clients and characteristics of the virus, and the characteristics of salon services, that I have elevated risk of contracting the virus simply by being in the salon. *

I have read and agree with the statement above.
I confirm that I am not presenting any of the following symptoms of COVID -19 listed below: *

I have read and agree with the statement above.
•    Temperature above 98.7
•    Shortness of breath
•    Loss of sense of taste or smell
•    Dry cough
•    Sore throat
•    Chills
• Muscle pain
I confirm that if I present symptoms between now and my appointment that I will cancel. I also understand that I can be denied services if I show up with symptoms. (Fees may apply) *

I have read and agree with the statement above.
I confirm that I have not been around anyone with these symptoms in the past 14 days. *

I have read and agree with the statement above.
I do not live with anyone that is sick, quarantined, or have tested positive for COVID-19. *

I have read and agree with the statement above.
To prevent the spread of contagious viruses and to help protect each other, Iunderstand that I will have to follow the salons strict guidelines. *

I have read and agree with the statement above.
I understand that air travel significantly increases my risk of contacting and transmitting the COVID-19 virus. *

I have read and agree with the statement above.
I understand that the CDC, OHSA and California Board of Cosmetology and Barbers recommend social distancing of at least 6 feet apart. *

I have read and agree with the statement above.
I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19 *

I have read and agree with the statement above.
I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days. *

I have read and agree with the statement above.
Signature

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