COVID-19 Health Self Screening Form

COVID-19 Health Self Screening Form

**Signature Required Prior to Every Scheduled Appointment**
Name *

First Name Last Name
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Society, a Salon is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the Washington State Governor's Office, Health Department , and CDC guidance.

Symptoms of COVID-19 include:
- Fever
- Fatique
- Dry Cough
- Difficulty Breathing
I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I do not have a fever above 100.4 degrees at the time of my appointment. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 14 DAYS. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 14 DAYS. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 14 DAYS. I understand that Society, a Salon cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.
I understand the following protocols, procedures, and policies : *

I understand I will have to wear a face masks at all times while in the building. Because of limited supply, I will try to provide my own masks, but Society can provide one will supplies last. My mask may become wet or come in contact with chemicals, so Society recommends bringing two disposable masks. I will upon entering the building immediately wash my hands for at least 20 seconds. I will reschedule my appointment with a show any symptoms of any sickness. I will try to give a 24 hour notice if possible. I will text my name and appointment time to 253-750-1508 when I arrive in the parking lot. I will stay in my car until I am notified that my stylist is ready for me. I will bring my own beverages and keep my personal belongings to only what is essential. I will come by myself to the appointment and bring no other people with me into the salon. I will use my credit or debit card if possible, and only use exact cash is that is not possible. I am forgoing signing a paper receipt and agree to be emailed my receipt if needed. I understand I may have to have my entire face covered during any time at the shampoo bowl. I will maintain social distancing from other stylists and clients as much as possible. I will refrain from touching as many multi-use surface as possible, including retail. I will as a member of Society to help with any retail needs.
I understand by checking the statements above, I am agreeing that they are true to the best of my knowledge and will adhere to all policies.

I understand by not checking any of the statements above will result in the cancellation of all appointments

By signing below, I agree to each statement above and release Society, a Salon from any and all liability for the unintentional exposure or harm due to COVID-19.

Society, a Salon agrees to abide by these standards and affirms the same.
Date *

Month Day Year
Date
Signature *

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