New Client Consultation Form

COVID-19 Spa Consent Form

Carolina Glam Makeup Studio & Skin Spa
Name *

First Name Last Name
Date *

Month Day Year
Appointment Date *

Month Day Year
Appointment Date *

Month Day Year
I knowingly and willingly consent to having makeup and esthetics service(s) during the COVID-19 pandemic at Carolina Glam by Keisha Moore at my own risk. *

by checking this box I understand and accept this statement.
To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the salon's strict guidelines. I will wear approved masks and or face coverings at all times while not receiving services. I will sanitize my hands during point of entry. I will maintain six (6) feet distance when possible. *

by checking this box I understand and accept this statement.
I confirm that I, nor anyone in my household have any of the following symptoms of COVID-19 listed below, nor have had anyof the following symptoms in the past 14 days: -fever -body aches -chills -headache -cough -new loss of taste or smell -shortness of breath -sore throat -difficulty breathing -congestion or runny nose -fatigue -nausea or vommiting -muscle aches -diarrhea *

by checking this box I confirm that I nor any of family have had none of these symptoms.
To the best of my knowledge, neither I nor anyone in my household has been in contact with anyone who has tested positive for COVID-19 *

by checking this box I understand and accept this statement.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. It is impossible to determine who has it, and who does not. I understand that Keisha Moore and Carolina Glam is doing everything in their power to determine healthy patrons prior to entry of the salon. *

by checking this box I understand and accept this statement.
I verify that neither I, nor anyone in my houseold have not traveled outside the United States In the past 14 days *

YES NO
In-salon Temperature Policy

I’m willing to take a temperature check during my visit to the salon before the services are started, and I agree not to come to the salon with the following symptoms of COVID-19 listed below: Fever- Temperature, shortness of breath, loss of sense of taste or smell, dry cough, runny nose or sore throat.
I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I willingly consent to release from any and all liability for the unintentional exposure or harm due to COVID-19. *

Yes
Signature *

Clear

COVID-19 Spa Consent Form

In-salon Temperature Policy