Name *

First Name

Last Name

Question 1: *

I understand that 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, given the current limits in virus testing.

YES, I understand

NO, I do NOT understand

Question 2: *

I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of hair services, that i have an elevated risk of contacting the virus simply by being in the salon.

YES, I understand

NO, I do NOT understand

Question 3: *

I confirm that i am NOT presenting any of the following symptoms of COVID-19 listed below: - A temperature above 98.7 degrees - Shortness of breath - Loss of sense of smell or taste - Dry cough -Sore throat

I confirm

I do NOT confirm

Question 4: *

I confirm that I have not been in contact with anyone with any of the above listed symptoms in the past 14 days.

I confirm

I do NOT confirm

Question 5: *

I confirm that I do NOT live with anyone who is sick or quarantined.

I confirm

I do NOT confirm

Question 6: *

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.

Yes, I confirm

NO, I do NOT confirm

Question 7: *

I confirm that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I understand that the CDC, OSHA, and the New Hampshire Board of Cosmetology and Barbers recommend social distancing of at least 6 feet.

YES, I understand

NO, I do NOT understand

Question 8: *

I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.

Yes, I verify

NO, I do NOT verify

Question 9: *

I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.

YES, I verify

NO, I do NOT verify

Date *

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