D'Arcy Hair Design: Health Certification Form
This form must be filled out prior to arriving for your service. If it is not filled out by 6pm the night before your scheduled appointment you will be notified to complete in order to receive a service. If you do not fill out the form, you will be declined service. Records will not be shared unless COVID19 is discovered by any client, owner or service provider inside the Emerson Salon location. Names will be kept confidential unless required by government agencies for contact tracing.
Email address *
Full Name *
Have you travelled by air out of Washington State or out of the country within the last 14 days? *
Required
Have you experienced the following in the last 14 days? Cough, Shortness of breath/ difficulty breathing, Fever, Chills, Muscle pain, Sore throat, or New loss of taste or smell *
Required
Scenario: You discover that an individual with whom you co-habitate with and/or have had close contact with (in the 14 days previous to your appointment) has been diagnosed with Covid19. Will you notify D'Arcy so she may take appropriate action to inform others of potential exposure? (Given no names are shared) *
Required
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