Loren's Hair Studio COVID-19 Client Pre-Screener
By completing and submitting this form, you are knowinly and willingly consenting to having beauty and or barber care services performed during the COVID-19 Pandemic and you agree to adhere to all safety and sanitation protocols now required by the salon and or shops' service provider.
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Email *
First Name *
Last Name *
Contact Cell/Phone Number *
My Baseline pre-visit temperature must be below 99 degree Farenheit to receive a service. Today my temperature is : *
I am aware that due to limited testing for the COVID-19, the virus has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it . *
I also acknowledge that I understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting the virus should it be present. *
I confirm that none of the following COVID-19 symptoms have been present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat,  Chills, Repeated Shaking with Chills, Muscle Pain or Head Ache *
I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the country I reside in. *
I affirm that I have not traveled domestically (outside of my state) or internationally (outside of my country) within the past 14 days. *
Do you suffer from allergies? If yes, explain what are your allergy symptoms. If no, then put "Not Applicable or N/A" below. *
I agree by providing my name below, I am in essence rendering my signature in acknowledgement of the  completed statements on this form and that all information is accurate as of the date of this form. *
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