Dees Beauty Salon

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COVID-19 CONSENT FORM


Name:
Date of Birth:
Dr Contact No:

In order to keep you, me and other clients safe it's vital that we minimise the risk of Covid-19 infection during your visit at Dee's Beauty.

Dee's Beauty advises that we postpone your procedure if you are at risk of having or developing Covid-19.

Please answer the following question below


COVID-19 SYMPTOM CHECKLIST (Please Select YES OR NO)

Have you travelled outside the UK in past 6 - 8 weeks ?
Do you currently have/or have you had in the past 7 days, any of the symptoms below?		 YesNo
Fever > 38°C or shivers/ chills? YesNo
Generalised aching or new headaches? YesNo
Coughing (new for you) YesNo
Shortness of breath (new for you) YesNo
Sore Throat YesNo
Runny nose or new nasal congestion YesNo
Loss of sense of smell or taste (new for you) YesNo

AND

In the last 2 weeks I have not been in contact with anybody who has been diagnosed with COVID-19 or is waiting for test results for COVID-19 or self-isolating because of possible COVID-19 symptoms.

I understand that if I have any of the above it is not safe for me to undergo any treatments and I would be putting myself and others at risk.

Signature:
Date: