Roman Beauty COVID-19 Form
COVID-19 Disclaimer Following the COVID-19 pandemic, we’ve put extra measures in place for the safety of you and our staff members. We require all clients to fill in our COVID-19 form before arrival so that we can provide the best possible and safe experience to our clients and staff members. Please carefully read and answer the below questions. This information will be stored confidentially and securely. If you or a member of your household has developed a cough, high temperature, fever, breathlessness, sore throat, headaches or loss/change in a normal sense of taste or smell within the last 14 days, or within a 14 day period leading up to any of your future appointments, please let us know and cancel your appointment giving as much notice as possible. Please get in touch if you have any questions - we’re looking forward to welcoming you back. Please note; we store your name and contact details and must give them to Track and Trace if requested.
Personal Information
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
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Please answer all of the below questions and choose one answer.
Do you, or anyone in your household, have any flu-like symptoms?
YES
NO
1. Are you experiencing a cough?
YES
NO
2. Are you experiencing a shortness of breath?
YES
NO
3. Have you had a fever (above 37.7C degrees) in the last 14 days?
YES
NO
4. Have you noticed a loss or change in your sense of taste or smell?
YES
NO
5. Have you had any contact with anyone that has suspected COVID-19 in the last 14 days?
YES
NO
Agreement
I have understood, read and completed this form truthfully to my knowledge. I confirm to my knowledge that I, my household or social bubble have not been in contact with anyone that has had symptoms of COVID-19 in the last 14 days, and if this changes within any 14 day period leading up to ANY of my future appointments at Roman Beauty Salon, I will notify Roman Beauty Salon immediately and cancel my appointment. I knowingly and willingly consent to having services at Roman Beauty Salon during the COVID-19 pandemic. If guidelines are not strictly followed, and I do not inform Roman Beauty Salon of any changes, I understand that Roman Beauty Salon has the right to cancel the appointment with the full cost of the service being charged and any other paid costs being non-refundable. I consent for the services to be carried out which involves a staff member of the team being in physical contact with me with less than 2 metres distance (with the recommended visor & facemask worn by staff, as per government guidelines for any treatments under a 1 metre distance). To prevent the spread of the virus and protect each other, I confirm that I will strictly follow guidelines and wear a mask to all of my appointments. I confirm that I release the staff member performing the service and as a business from any and all liability for the unintentional exposure or harm due to COVID-19
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