covid intake form

Due to the covid-19 pandemic, we are taking extra precautions with the intake of each client. However, this is not only for covid-related illness, but for any condition that may be a risk factor in receiving a tattoo or possible exposure to others within the studio.

We would like to keep Crown & Serpent studio as safe as possible for everyone who enters the premises.

Please, if you have ANY illness symptoms for covid or any cold/flu (or other contagions/conditions), reach out to your artist/technician directly and reschedule your appointment.

PLEASE READ THROUGH THE FOLLOWING CAREFULLY:

I affirm that I, as well as members of my household, do not currently have nor have experienced any covid symptoms (dry cough, fever, excessive fatigue, difficulty breathing, sore throat, loss of smell or taste, etc.) or any other cold/flu symptoms (runny nose, coughing, etc.) within the last 14 days. (allergy symptoms are an exception but please be sure your symptoms are indeed allergy-related.)

I affirm that I, as well as members of my household, have not been diagnosed with covid-19 and have not been in contact with anyone who has been diagnosed with covid-19.

I affirm that if I have traveled outside of Canada in the last month, I have isolated in my home for 14 days upon my return.

I affirm that I do not have MRSA, Hepatitis B (HVB), Hepatitis C (HVC), or human immunodeficiency virus (HIV).

If my appointment involves receiving a tattoo, I affirm that I am not pregnant or breastfeeding.

I have read the above affirmations, and I agree, to the best of my knowledge, that I do not have any of the above symptoms/contagions of concern. *

Yes, I agree.

I understand that, because personal services practices involves maintaining prolonged and close physical contact, there may be elevated risk of disease transmission in the event that no symptoms are present during the time of the procedure. *

Yes, I understand.

I understand that Crown & Serpent Body and Soul Inc. and my artist/technician cannot be held liable should I experience exposure to the covid virus or any other contagion as a result of myself or another client providing misinformation on this form. *

Yes, I understand.

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive a body modification and/or personal services session. *

First Name Last Name

Your email address: *

Your appointment date: *

Please select your artist/technician for your appointment: *

INTAKE FORM