PrismatiqueMaven - Covid-19 Salon Services Consent Form

COVID-19 SERVICE CONSENT FORM

By submitting this form, you agree to have Prismatique Maven services during the pandemic. This form must be completed on the day of your appointment, or at least 12 hours ahead of time to your appointment.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
PART A
By checking the boxes, you indicate that you agree to the following statements: To obtain services for your next day/or current day appointment, all boxes must be checked:

I agree to obey the rules of the salon during my appointment in order to minimize the spread of viruses.I agree to remove all hand jewellery ( rings , bracelets ,etc) if I getting a manicure /nail extension service.
PART B
Are you currently experiencing any of the following COVID-19 related symptoms in the past 24 - 48 hours?
Cough [ Onset / Worsening of existing cough]

YESNO
Diarrhea

YESNO
Fatigue

YESNO
Fever (higher than 38 degrees C)

YESNO
Having chills

YESNO
Headache

YESNO
Muscle pain or body aches

YESNO
New loss of taste or smell

YESNO
Runny nose or nasal congestion

YESNO
Shortness of breath

YESNO
Sore throat

YESNO
Vomiting

YESNO
Nausea

YESNO
PART C
Have you experienced any of the above [ PART B ]symptoms within the last 14 days?

YESNO
Are you currently waiting on the results of a COVID-19 PCR Test?

YESNO
PART D
Have you had any of the following encounters in close physical contact with any of the following for a total of 15 minutes?
Anyone who is known / presumed to be Positive to have laboratory confirmed case of COVID-19

YESNO
Anyone who has displayed any of the symptoms listed in Part B COVID-19

YESNO
Living / Come In Contact with someone who has been asked to self-isolate

YESNO
Living / Come In Contact with someone who has exhibited COVID-19 related symptoms

YESNO
Living / Come In Contact with someone who has returned from an international trip

YESNO
PART E
Have you recently returned from international travel, or were asked to self-isolate by a health care professional, and have not yet completed the mandated 14-day self isolation period ?

YESNO
I was immunised against the Covid-19 virus. (Vaccinated)

YESNO
If Yes . I have received immunisation (Vaccinated)of

I've received Both dosesI've received my first dose and am waiting for my second.
PART F
I agree not to visit the salon for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete.

If YES was answered to any of the above questions, please contact to cancel your appointment.

If you answered NO to all of the above questions you have passed the screening and can report to the salon.

Please be aware: Immediately wash your hands for at least 20 seconds right after you enter the facility Do not shake hands or do not touch/hug others Keep a 2m distance from other clients? staff, Wear a mask.

No Extra People /Pets are allowed permitted. Only person's receiving a service is allowed to an appointment .

I confirm that I understand and agree to all of the conditions and statements in this form by signing below.

By signing below, I acknowledge that I have read and understood the facility regulations and that the information I have provided is accurate and complete.
Parent/Guardian Name (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Client/Parent/Guardian Signature

Clear
Should be Empty:

COVID-19 SERVICE CONSENT FORM

PART A

PART B

PART C

PART D

PART E

PART F