Client Declaration Form
Please fill out the following declaration form. Submissions are valid up to 24 hours prior to treatment.
Full Name
Phone
Email
Do you have any allergies and/or suffer from any skin conditions or infections?
No
Yes
Have you had any symptoms of illness in the last 7 days?
No
Yes
Prior to the start of my treatment, I can confirm that:
I do not have a pending COVID-19 Test.
I have not been diagnosed with or cared for anyone with COVID-19 in the past 2 weeks.
I have not shown signs or been in close contact with anyone that is exhibiting these symptoms: COUGH, FEVER/CHILLS, SHORTNESS OF BREATH, DIFFICULTY BREATHING, SORE THROAT, LOSS OF TASTE OR SMELL, FATIGUE, HEADACHE, CONGESTION, OR RUNNY NOSE, NAUSEA OR VOMITING OR DIARRHOEA
I have not traveled internationally within the last 14 days.
If I begin to show symptoms of COVID-19 within the next two weeks, I will contact my artist (Ruby Jones).
Date
Initials
I confirm that all information above is correct. I accept that any treatment I have taken is at my own risk. I certify that I have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request. If I have any allergen concerns I will discuss these with my artist before any treatment.
Submit
Thanks for submitting!
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