Client intake form
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Name *
Phone Numer *
Email *
Health Information
Have you traveled outside the United States in the past 14 days to countries that have been affected by COVID-19? *
Have you traveled domestically within the United States by commercial airline, bus, or train within the past 14 days? *
Have you knowingly come into contact with someone who has been or potentially has been exposed to COVID-19 in the last 14 days? *
Have you experienced any of the following symptoms in the last 14 days? Fever, sore throat, chills, cough, shaking, muscle pain, shortness of breath, runny nose, or loss of taste or smell *
Have you started any new medications (oral or topical), or new supplements? *
Are you currently pregnant, trying to become pregnant or breastfeeding? *
On a scale of 1-10, what would you rate your stress levels since your last visit? *
Skin Health Skincare routine:
Skin Health Skincare routine:
Exfoliator:
Serums:
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Eye Cream:
Moisturizer:
Masks:
SPF
Skin Concerns:
• I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID19. • To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the salon's strict guidelines, including: • Maintaining a social distance of at least six feet • Taking a temperature check upon salon entry before my service can begin • I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not give the current limitation of virus testing. • I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when visiting (business name). By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive skincare services from my esthetician. *
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