Appointments Appointment Request and COVID-19 Screening ChecklistName*Phone*Requested appointment date*Reqested appointment time*Based on the US Center for Disease Control Guidelines, service providers, daily, are encouraged to screen all clients for signs of respiratory illness accompanied by fever. All clients entering our Salon must be asked or complete the questions below. Records will be available upon request from the Public Health Department.Truthful content* By checking this box, I pledge to provide only correct and truthful information when completing this screening.Did you had any of the following respiratory symptoms in the past 14 days?New or worsening cough?YesNoHave you had temperature 100.4*F or greater in the past 14 days?YesNoHave you been in close or proximate contact with confirmed or suspected COVID-19 case in the past 14 days?YesNoHave you been tested positive COVID-19 in the past 14 days?YesNoIf you have answered YES to any of the above questions, please call and cancel your appointment immediately and follow up with your primary care physician. If you have answered NO to all questions above, you will be allowed entry to our salon.Please observe the following protocols at your appointment. The waiting area in the salon is closed so please be patient and wait outside for your turn. We will let you know when to come in. Wash your hands for at least 20 seconds upon entry in the salon, you can also use the hand sanitizer or the disinfecting solutions at the front desk/reception. You must wear a mask or a face covering at all times during your visit in the salon. If you don't have a mask we will provide you with a complimentary mask. Please do not shake hands, touch or hug others during your time in the salon. By signing*By signing the form below I am acknowledging the potential risk to contract the COVID-19 disease during services provided today and voluntarily agreed to accept services. You further agree and hereby release our Salon and its employees from any and all liability associated with your potential risk to contract NOVEL CORONAVIRUS (COVID-19).Yes, I agree.Signature (please type)*DateTimeSendThis field should be left blank