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Barber Shop Consent -Form Fill
Q1
First Name
Client Name
Q2
Last Name
Client Name
Q3
By checking the boxes, you confirm that you agree with the following statements:
I understand that I have a risk of contracting virus during the service.
I agree to obey the rules of the barber shop during my appointment in order to minimize the spread of viruses.
I confirm that I have not been diagnosed with COVID-19 last 14 days.
I verify that I am not waiting for the laboratory test results for COVID-19.
I am willing to take a temperature check before the services are started.
I have not traveled internationally within 14 days.
Q4
Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell
Yes
No
Q5
Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or get infected?
Yes
No
Q6
Are you living with anyone that is get infected or quarantined due to COVID-19?
Yes
No
Q7
First Name
Parent/Guardian Name (if applicable)
Q8
Last Name
Parent/Guardian Name (if applicable)
Q9
Date
Q10
Client/Parent/Guardian Signature
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