Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Appointment

MM

DD

YYYY

In the past 14 days, have you or anyone in your home had any contact with any individual that has tested positive for COVID-19 or anyone exhibiting symptoms of Coronavirus? *

Yes

No

In the past 14 days have you tested positive for COVID-19? *

Yes

No

In the past 24 hours, have you or anyone in your home had a fever of 100 degrees or more? *

Yes

No

Are you or anyone in your home sick at this time? *

Yes

No

In the past 14 days have you traveled domestically or internationally by commercial airlines?

If so, please reschedule for 14 days after the end of your travel.

Yes

No

Do you work in an industry that is considered a potential Coronavirus hotspot?

Depending on answer, we might contact you for further information before approving or denying your appointment.

Yes

No

Are you experiencing any of the following? *

-New or worsening cough -Sore throat -Fever or chills -Shortness of breath/Difficulty breathing -Cold/Flu symptoms -New loss of taste or smell

Yes

No

In the past 14 days have you adhered to the following CDC guidelines?

-Practicing social distancing -Wearing a mask when out on public -Practicing appropriate hand hygiene including frequent hand washing & use of hand sanitizer -Avoiding potential exposure to high risk individuals

Yes

No

Do you understand that Covid-19 is a highly contagious virus that is easily spread from person to person?

Yes

No

In addition to the long-held sanitary measures that Marjorie May LLC has always adhered to, new preventative measures have been put in place to further reduce the spread of COVID-19. However, these best practices still offer no guarantee regarding your potential risk of infection. Do you understand and agree to associated risk?

Yes

No

CONSENT FOR SERVICES. Esthetics and Nail Technology involves maintained touch and close physical proximity over an extended period of time. Do you understand that waxing, lash, and nail services hold an elevated risk of transmission of Coronavirus?

Yes

No