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* 1. First and Last Name of Client Receiving Services

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* 2. If you are the parent/guardian of your child/dependent who is under age 18 and receiving the service(s) today, print your first and last name below and proceed to complete this form for your child/dependent

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* 3. Email Address (if client is under age 18, provide parent/guardian's email

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* 4. Cell Phone Number (if client is under age 18, provide parent/guardian's cell phone number)

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* 5. Today's Date and Time of your Appointment

Date
Time

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* 6. Have you had ANY of the following symptoms within the last 14 days: cough,  headache, sudden loss of taste and/or smell, shortness of breath or difficulty breathing, fever over 100 degrees F, sore throat or body aches?

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* 7. Have any members of your household had ANY of the following symptoms within the last 14 days: headache, cough, shortness of breath or difficulty breathing, sudden loss of taste and/or smell, fever over 100 degrees F, sore throat or body aches?

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* 8. Have you been in contact with ANYONE within the last 14 days with ANY of the following symptoms: headache, cough, shortness of breath or difficulty breathing, sudden loss of taste and/or smell, fever over 100 degrees F, sore throat or body aches?

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* 9. I understand that the COVID-19 virus has up to a 14 day incubation period which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

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* 10. I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of hair services, that I have an elevated risk of contracting the virus simply by being in the salon.

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* 11. I confirm that I am not presenting any of the following symptoms of COVID-19 (or have not been around anyone within the past 14 days of my appointment who have had these symptoms): fever over 100 degrees F, shortness of breath or difficulty breathing, loss of sense of taste and/or smell, headaches, cough, sore throat, or body aches. 

I understand that should I, or someone I live with, present symptoms after my appointment, I will notify my stylist immediately.

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* 12. I verify that I, or someone I live with, have not traveled outside the United States in the past 30 days.

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* 13. I understand that if I, or someone I live with, currently have any symptoms or have tested positive in the last 14 days, or have a PENDING TEST for COVID-19 that my appointment will need to be rescheduled and I will not be able to receive services today.

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* 14. I confirm I am not living with someone who is currently sick or quarantined.

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* 15. I knowingly and willingly consent to have hair services during the COVID-19 pandemic. I have answered the questions to the best of my knowledge. By clicking "I Agree" to this statement and the above statements and questions, I release Expressions Hair By Stephanie/Stephanie Lindemuth from any liability related to COVID-19 and its risks and make this legally binding as an e-signature. 

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* 16. If you are the parent/guardian of your child/dependent and have filled out this form for your child/dependent who is the client receiving services today, please read the following statement and provide your e-signature: 

I, the parent/guardian of the child/dependent receiving hair services today, knowingly and willingly consent to them having hair services during the COVID-19 pandemic. I have answered the questions for my child/dependent to the best of my knowledge. By clicking "I Agree" to this statement and the above statements and questions, I release Expressions Hair By Stephanie/Stephanie Lindemuth from any liability related to COVID-19 and its risks and make this legally binding as an e-signature.

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