COVID19 Questions and Release Form

Purpose: Based on the US Center for Disease Control Guidelines, service providers, daily, are encouraged to screen all clients for signs of respiratory illness accompanied by fever.
Instructions: All clients entering Face Value Salon must be asked the following questions below. Face Value will maintain this record for 14 days from completion of this form and have this form available upon request from the Public Health Department.
1. Do you have any of the following respiratory symptoms?
New or worsening cough?
New or worsening shortness of breath?
2. Have you had a (temperature 100.4*F or greater within the last 14 days)?
3. Are you feeling feverish?
4. Are you having chills?
5. Have you been in a facility or home with confirmed COVID-19 by lab test within the last 14 days?
6. Have you been with persons with confirmed COVID-19 by lab test within the last 14 days?
If you answered YES to any of the above questions, we will cancel and reschedule your appointment immediately. If NO to all, proceed to remaining statements.
If you answered NO to all questions you may proceed with your service. Please be aware of the following protocols:
  • You will disinfect hands with hand sanitizer upon entering salon
  • Masks MUST be worn throughout services
  • Do not shake hands with, touch or hug others during your time in the building
  • Do not congregate in any space within the salon


2050 Bond Street, Suite 130
Charlottesville, VA. 22901
434 984-1254

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