Name *

First Name

Last Name

Phone Number *

(###)

###

####

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 in close contact with anyone exhibiting these symptoms in the past two weeks. *

I have not traveled outside of my daily routine for the past two weeks *

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

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

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

Date *

MM

DD

YYYY