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Thank you for scheduling an appointment at Four Star Tattoo, we look forward to working with you! For everybody’s safety we are screening all clients for symptoms of COVID-19 before arrival. By answering these questions, you are helping us protect the health and safety of the staff and clients of Four Star Tattoo, as well as the community around us.

Please answer the following questions no more than 24 hours prior to the time of your appointment. You must answer these questions to secure your appointment.

In the last fourteen (14) days:

 

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Have you tested positive for SARS-CoV-2 or been diagnosed with COVID-19, or been identified as a potential carrier of this virus or any similar communicable illness?
No
Yes
Have you experienced a prolonged cough?
No
Yes
Have you had a fever (above 100.4 deg F.)?
No
Yes
Have you experienced a shortness of breath?
No
Yes
Have you experienced a loss of taste or smell?
No
Yes
Have you been in close, unprotected contact (longer than 15 minutes within 6 feet) with a suspected or known Coronavirus carrier, or someone exhibiting the above or other symptoms of COVID-19?
No
Yes
Date of signing
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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