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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. I understand that I may not enter the Salon Lofts building until I have received a text message from Stephanie that she is ready for me to enter her loft. Due to Salon Lofts waiting areas being closed, when I arrive for my appointment, I must remain outside or in my car, text her that I have arrived, and wait for her to inform me that she's ready for me to enter the building. I must wash my hands with soap and water for a minimum of 20 seconds at the sink (either in the hall or in the restroom), prior to entering Stephanie's loft. This survey must be submitted the same day as my appointment, prior to entry to Expressions Hair By Stephanie/Stephanie Lindemuth's loft, it may not be submitted earlier than the day of my appointment.

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* 7. Have you had ANY of the following symptoms within the last 14 days (regardless of whether you believe it's not COVID-19 related): 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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* 8. Have any members of your household had any of the following symptoms (regardless of whether they believe it's not COVID-19 related) within the last 14 days: cough, headache, 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 I must inform Expressions Hair By Stephanie/Stephanie Lindemuth of any of symptoms I have, that are listed in the questions above, even if I know/believe they are not COVID-19 relatedPRIOR to entry to her loft. If it is determined that there is any cause for concern or that I have any of the symptoms listed in the above survey questions, Expressions Hair By Stephanie/Stephanie Lindemuth reserves the right to reschedule my appointment, even if these symptoms/concerns are not discovered until after it has begun/I arrive. For this reason, it is my responsibily to inform Expressions Hair By Stephanie/Stephanie Lindemuth PRIOR to entry to her Loft, if I have any of the above symptoms, in order to prevent my appointment from being rescheduled after I have arrived/it has begun.

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* 10. Have you been in contact with ANYONE within the last 14 days with any of the following symptoms (regardless of whether they believe it's not COVID-19 related): 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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* 11. 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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* 12. 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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* 13. I confirm that I am not presenting ANY of the following symptoms (or have not been around anyone within the past 14 days of my appointment who have had these symptoms): cough, fever over 100 degrees F, shortness of breath or difficulty breathing, loss of sense of taste and/or smell, headaches, 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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* 14. 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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* 15. 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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* 16. I understand that in the event that I have tested positive for COVID-19 within 30 days of my appointment today, I must provide my stylist with either 1) a negative COVID-19 test result with documentation that I have been cleared/released from quarantine, OR 
2) if I cannot obtain a second COVID-19 test to demonstrate a negative result, I must postpone my appointment to a minimum of 30 days from the date I have been cleared/released from quarantine and provide documentation of the date that I have been cleared/released.

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

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* 18. 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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* 19. 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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