COVID19Safe Consent Logbook
JAVANESE BEAUTY
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PLEASE READ AND ANSWER CAREFULLY. During these uncertain times with COVID-19 pandemic, we have been following the situation closely and are keeping abreast of government guidelines. This form is for COVID-19 contact tracking. It is a government requirement to help assist the tracking of COVID-19 outbreaks in Western Australia. You have to SUBMIT this form PRIOR your appoinment. Javanese Beauty have the right to cancel and re-scheduled your appointment, if you haven't submit it by the latest tonight.
First Name *
Surname *
Parent or Guardian (In Case of Minor only) Full Name:
Appointment Date: *
MM
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DD
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Mobile Number *
Have you had recovery from COVID-19 in the last 2 weeks or 3 weeks? *
Do you have any of the following symptom(s) in the past 14 days, few days or present? *
Required
Have you or someone in close contact live with any person or frontline workers / nurses who look after a confirmed or suspected  COVID-19 cases in the past 14 days or recent? *
Required
Are you a Frontline Worker / Nurse or someone who look after a confirmed or suspected COVID-19 cases in the last 14 days or recent? *
Required
Have you travelled Interstate or Overseas in the last 2 weeks or 3 weeks? *
Required
Do you have anyone in your household who have been travelling Interstate or Overseas in the last 2 weeks or 3 weeks? *
Required
Have you been in contact with someone/ relatives/ friends, who are confirmed or suspected COVID-19 patient in the last 2 weeks or recent?   *
Required
Do you have anyone living in or visiting your home that has travelled from Interstate or Overseas in the last 2 Weeks / 3 Weeks? *
Required
Covid-19 is a highly contageous virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measure have been put into place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.
By completing this pre-entry consent logbook form, you have acknowledged your responsiblilities in managing your own personal health in relation to COVID-19 and confirmed all of the above information is true and correct.
CLIENT DISCLAIMER
I understand that because practices in this facilities can and do involve being touched and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledged that I am aware of the risks involved from receiving treatment at this time. I agree to assume those risks, and I release and hold harmless to the Beauty Therapist or Makeup Artist of Javanese Beauty from any claims related thereto. I give my consent to receive treatment from the Beauty Therapist or Makeup Artist of Javanese Beauty. *
Required
If you answered YES to any of the above, we are appologise that our Beauty Therapist or Makeup Artist of Javanese Beauty can NOT provide a service for your appointment and we would recommend you to seek a medical advice / treatment. Your appointment will need to be rescheduled for at least another 14 days.
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