Client Health Statement

Client Heath Statement

Please read and sign the following verification statement prior to start of your service:

I have not been quarantined within the last 14 days due to COVD-19 symptoms or illness. I agree that I am not showing any symptoms today.*

I Agree
I Disagree

I do not have a cough*

I Agree
I Disagree

I do not have a fever*

I Agree
I Disagree

Have you travelled by plane or other public transportation in the past 14 days?*

Yes
No

I have not been around anyone exhibiting these symptoms within the past 14 days*

I Agree
I Disagree

I am not living with anyone who is sick or quanrantined*

I Agree
I Disagree

Do you work or live with anyone who deals directly with COVID-19 patients or have/has been around person(s) with COVID-19 or displaying COVID-19 symptoms in the past 14 days?*

Yes
No

If yes to the above, continue to fill out this form and contact immediately prior to your appointment.*

I Undersrand

I have the right to deny service based upon certain health guidelines provided by the State of Texas and the CDC to ensure the safety of myself, family, clients and others in the salon.

If I start to show symptoms for COVID-19 within 7 days, I will contact my stylist/salon owner.*

I Agree

Full Name

First Last

Phone

Email

Date of Service

Service Time:

: HH

MM

By submitting this form I agree that I have not been in contact with anyone who has displayed symptoms or who has contracted COVID-19. I also agree that I have not displayed symptoms or have contracted COVID-19. I understand that by filling out this form keeps everything safety, including mine, a first priority. I consent that this information is accurate and that my initials below will suffice as my signature for this form.*

I Consent

Initials (Used as Signature)