Risk Acknowledgement Form

For the safety of our clients and coworkers, please take the time to fill out the information below.

Most common symptoms of COVID-19 include:

Fever, fatigue, dry cough, and difficulty breathing.

Risk Acknowledgement Form

First & Last Name

I affirm that I , nor any member of my household have had any of the symptoms listed above in the past 14 days.

Phone

I affirm that I, as well as anyone in my household, has not been knowingly exposed to someone diagnosed with COVID-19 in the past 30 days.

I affirm that I, as well as anyone in my household, has not been out of the country or province or to any area that is considered a “hotspot” for COVID-19 in the past 30 days.

I understand that PIERINO SCARFO SALON and it’s salon professionals have implemented recommended disinfection protocols but the risk of infection of COVID-19 still exist. I am attending my appointment with the knowledge of that risk.

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!