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Renarde Salon Health Questionnaire 

  • I have not shown symptoms of or been diagnosed with COVID-19 in the previous 14 days. Symptoms include: fever or chills; cough; shortness of breath or difficulty breathing; fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting.
  • I have not cared for someone with suspected or confirmed  COVID-19 in the previous 14 days.
  • I have not traveled within the previous 14 days.
  • If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Renarde Salon.
  • I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

​September 30, 2020

 

 

First Guest Name

First Name*

Last Name*
First Guest Date of Birth*
I certify that I am 18 years of age or older
First Guest Signature*
Second Guest Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email*

Confirm Email*
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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