QUESTION 1 *

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks.

I agree

QUESTION 2 *

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.

I Agree

QUESTION 3 *

I have not travelled outside of my immediate daily routine for the past two weeks

I Agree

QUESTION 4 *

I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell

I Agree

QUESTION 5 *

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact my stylist

I Agree

QUESTION 6 *

I will follow all posted salon rules to keep myself, my therapist, stylist and those around me safe

I Agree

Name *

First Name

Last Name

Date

MM

DD

YYYY