COVID-19 Release Form

Pre-Visit Questionaire

Please complete and submit the following form NO MORE THAN 24 HOURS before your scheduled appointment.
Let's make sure we both are doing the best we can to keep each other safe.

Date of Appointment*
Date Format: MM slash DD slash YYYY
Name*
First Last
Phone*
Email*
I knowingly and willingly consent to have a hair/skin service at La Muse Beauty Salon during the COVID-19 pandemic.*
- I agree.
I understand that COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly-contagious. It is impossible to know who has the virus and who does not have the virus due to current limits of virus testing.*
- I agree.
I verify that I have not traveled outside of the State of Oregon within the last 14 days.*
- I agree.
I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of La Muse Beauty Salon service, that I have an elevated-risk of contracting the virus simply by being in the salon.*
- I agree.
I confirm that I am not presenting any of the following symptoms of covid-19 as listed following: fever/temperature, shortness of breath, loss of sense of taste or sense of smell, dry cough, runny nose (not allergy related), sore throat.*
- I agree.
To prevent the spread of contagious viruses, and to help protect each other, I understand that I will have to follow the Salon’s strict guidelines as imposed by The State of Oregon.*
- I agree.
I understand that air-travel significantly increases my risk of contracting and/or transmitting the covid-19 virus. I understand that the CDC, OSHA, and Oregon Health Licensing Agency recommend social-distancing of at least 6 feet.*
- I agree.
Consent*
By submitting this, I hereby acknowledge that I have read, understand, and agree with the La Muse Beauty Salon appointment, guidelines, procedures, and requirements.
Email
This field is for validation purposes and should be left unchanged.