Name *

First Name

Last Name

Phone *

(###)

###

####

*

I knowingly and willingly consent to have this beauty treatment despite the COVID-19 + social distancing climate.

I Consent

I Do Not Consent

*

I knowingly and willingly consent to have this beauty treatment despite the COVID-19 + social distancing climate.

I Consent

I Do Not Consent

*

I understand, due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of treatments, that I have an elevated risk of contracting the virus simply by being in a salon.

i Consent

I Do Not Consent

*

I understand the inability for both myself + my artist to be socially distanced during my appointments puts me at risk for person to person transmission.

i Consent

I Do Not Consent

*

Please Select If You Are Presenting Any of the Following Symptoms of COVID-19

Fever of 99_+

Chills

Cough

Shortness of Breath or Difficulty Breathing

Fatigue

Muscle or Body Aches

Headache

Loss of Smell or Taste

Congestion or Runny Nose

Nausea or Vomiting

Diarrhea

None of the Above

*

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

I Understand + Ackowlegde

*

I verify that I have/have not traveled outside of the US or into hot spots in the US in the past 14 days.

I Have

I Have Not

*

I verify that i have/have not been in contact with someone who has COVID-19.

i Have

I Have Not

*

I understand that Lashes a la Mode is NOT responsible for the exposure i may encounter via clients + staff. I will abide by salon sanitation guidelines including handwashing, sanitizing, face covering and all other safety procedures set by Lashes a la Mode.

I Understand