Ageless Perfection Skin Care Studio HEALTH      Screening RE-VISIT Form
This REQUIRED form will be kept as an individual client record for studio guest each time they come in for their scheduled service/product pickup appointment. It is required to ensure that no one is exposed to a contagious illness and there are no symptomatic signs of the illness during the visit.  You agree to adhere to all safety and sanitation protocols now required by the Ageless Perfection Skin Care Studio to keep individuals with compromised immune systems safe.

                                                 PLEASE PROVIDE TRUE AND FACTUAL INFORMATION.  
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Email *
First Name *
Last Name *
Do you have any of the following symptoms present today or in the last 2 days: Extremely Tired, Fever, Shortness of Breath, Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Diarrhea/Nausea, Muscle Aches/Pain, Headache, Pink Eye, Congestion, Pressure in Chest? IF YOU HAVE HAD ANY OF THESE SYMPTOMS, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I am aware and understand that I am REQUIRED to wear a mask at all times, unless receiving a facial or facial treatment. If I arrive not wearing a mask, I will be given a mask to wear.  *
Have you been in contact with anyone that has been diagnosed with the COVID-19/FLU/RSV virus in the past 7 days? IF YOU HAVE HAD ONE OF THESE VIRUSES OR HAVE BEEN IN CONTACT WITH SOMEONE DIAGNOSED, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
Signature (Type Below) *
Date *
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Time *
Time
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A copy of your responses will be emailed to the address you provided.
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