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COVID-19 Pandemic Hair Treatment Consent Survey Form
Please take a few moments to complete this survey
1
Step 1
2
Step 2
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Name:
*
First Name
*
Last Name
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Date:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Name of Stylist for upcoming visit :
Tracy Lutz
Not Sure
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I knowingly and willingly consent to having hair and salon service(s) during the COVID-19 pandemic.
by checking this box I understand and accept this statement.
by checking this box I understand and accept this statement.
this field is required.Please Enter Value
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.
by checking this box I understand and accept this statement.
by checking this box I understand and accept this statement.
this field is required.Please Enter Value
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I know that the CDC, OSHA, and North Dakota state board of cosmetology recommend social distancing of at least 6 feet.
by checking this box I understand and accept this statement.
by checking this box I understand and accept this statement.
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Next
I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of hair services, that I have elevated the risk of contracting the virus by merely being in the salon company
by checking this box I understand and accept this statement.
by checking this box I understand and accept this statement.
this field is required.Please Enter Value
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing
by checking this box I understand and accept this statement.
by checking this box I understand and accept this statement.
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I verify that I have not traveled outside the United States In the past 14 days to countries that have been affected by COVID-19 :
Yes
No
N/A
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I confirm that I have or have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days:
Yes
No
N/A
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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 t
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 understand that this document is to provide the best possible guest ex
Yes
Yes
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*
Signature:
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