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.

First Name

Last Name

Email Address

Phone Number

Date

1. Do you have any of the following respiratory symptoms?

New or worsening cough?

Yes   No

New or worsening shortness of breath?

Yes   No

2. Have you had a (temperature 100.4*F or greater within the last 14 days)?

Yes   No

3. Are you feeling feverish?

Yes   No

4. Are you having chills?

Yes   No

5. Have you been in a facility or home with confirmed COVID-19 by lab test within the last 14 days?

Yes   No

6. Have you been with persons with confirmed COVID-19 by lab test within the last 14 days?

Yes   No

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

By checking this box and submitting this form, I pledge to have provided only correct and truthful information when completing this screening. I am acknowledging the potential risk to contract the COVID-19 disease during services provided today and voluntarily agreed to accept services. You further agree and hereby release Face Value Salon and its employees from any and all liability associated with your potential risk to contract NOVEL CORONAVIRUS (COVID-19).

Submit

Stonefield

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

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info@facevaluesalon.com