First Name
Last Name
Address
Tel Number
Email Address
DOB
Allergies
How Did You Hear About us
Date Taken
I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks I have not shown symptoms of COVID-19 or come into close contact with anyone exhibiting these symptoms in the past two weeks I have not traveled outside of my immediate daily routine for the past two weeks I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell If I begin to show symptoms of COVID-19 within the next 2 weeks, I will contact my stylist I will follow all posted salon rules to keep myself, my stylist, and those around me safe
I accept that any treatment I have is taken at my own risk. I certify that I have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above my result in adverse side effects, I accept full responsibility/liability for any side effects as a result of false or misleading information and agree that the therapist and or business holds no reasonability for any/all side effects of any treatment that you (the customer) may experience due to any treatment or patch test. I am aware that it is my responsibility to inform the therapist of my current and/or ongoing medical and/or health conditions and it is essential for the care given to execute appropriate treatment procedures. I acknowledge the possible side effects of any beauty procedure.
Customer Signature
Therapist Signature
By submitting this form, I give consent to be contacted further regarding services provided, or regarding any issues raised. No personal data is distributed further, however, and all data is protected under GDPR laws.
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