top of page

COVID-19 Pre-Screen Questionnaire

By completing and submitting this form, you are knowingly and willingly consenting to having beauty care services performed during the COVID-19 Pandemic and you agree to adhere to all safety and sanitation protocols now required by the salon and or shop's service provider.

Before your visit please be sure to review to our policy on guest and extra individuals at our salon. By completing and submitting this form you are agreeing to adhere to our salon policies. 


  • No extra individuals or children will be permitted other than the guest receiving service.

  • All appropriate screening and guest forms should be completed prior to service.

  • Face masks shall be worn when coming in for service. (We will provide if necessary).

  • Temperature check upon entry to salon. 

  • Hands must be washed immediately upon entering the salon.

  • If we are at the maximum capacity for the salon (10) you may be asked to wait until we finish guest to enter.

I confirm that none of the following COVID-19 symptoms have been present within the last 2-14 days: Fever, Shortness of Breath, Loss of Taste or Smell, Dry Cough, Runny Nose, Sore Throat, Chills, Bodyaches, Headache 

I am aware that due to limited testing for the COVID-19, the virus has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it .

I also acknowledge that I understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting the virus should it be present. 

I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days.

I affirm that I have not traveled domestically (outside of my state) or internationally (outside of my country) within the past 14 days. 

I agree by providing my name below, I am in essence rendering my signature in acknowledgement of the completed statements on this form and that all information is accurate as of the date of this form.

Thanks for submitting!

bottom of page