Statement of Health
To finalize your appointment confirmation, please complete this Statement of Health. Must be completed within 24 hours of receiving request.
I,________ , have not been quarantined within the last 14 days due to COVID-19 symptoms or illness, and I am not showing symptoms today. (Type your First and Last Name)
Additionally, Please read and sign the following certification statement prior to the start of your service:
I do not have a cough
I do not have a fever
I have not been around anyone exhibiting these symptoms within the past 14 days.
I am not living with anyone who is sick or quarantined.
If I start to show symptoms for COVID-19 within 7 days, I will contact my stylist or the salon directly at 877.316.3061.
Signature (sign by typing out your full name in between forward slashes), as so; /First Last/ If you are a guardian signing for a child type child's name, your relationship and add your signature in the same way, as so;Child's Name, Mother, /First Last/
Date of Service
America Ortega of AmericaO Beauty
Karolina Oliveros of Hair by Karolina Oliveros
Elia Orozco of Elia's Beauty Salon
Elizabeth Schattner of The Angel's Are Hair
I understand that the new COVID-19 protocols come with a signification cost increase to the salon. In order for the salon to open, a new Sanitation Fee, due directly to the salon, will temporarily be $2. I understand the mask rule and I will arrive with a mask or ask to wear a washed reusable mask or purchase a medical single use mask for $2. I understand mask availability is limited and I understand that if the salon is out of masks that I will have to reschedule if I do not have one on with me.
Yes I understand
No, I would like to wait until the fee and safety requirements are no longer required. Please cancel appointment.
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This form was created inside of Modern Love Salon.