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Each appointment must fill this form out everytime they come in. 

For the safety and protection of the health of our practitioners and clients we are implementing additional safety measures in compliance with the safety precautions published by the Center for Disease Control, State of Minnesota, and MN Board of Cosmetology.

If you have any symptoms of illness, Mindful Practice LLC and Lovdahl Salon & Studio LLC require you to reschedule your appointment once you are symptom free. Examples of 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

Diarrhea

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 7 days.

I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 14 days.

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 14 days.

I affirm that I, as well as all household members, have not traveled outside of the country or to any city or state considered to be a “hot spot” for COVID-19 infections within the past 10-days.

I understand that Mindful Practice LLC and Lovdahl Salon and Studio LLC cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

I understand that Mindful Practice LLC and Lovdahl Salon and Studio LLC are taking extra precautions in order to preserve the health of the practitioners and their clients.

I agree to cancel or reschedule my appointment if I, as well as any household members, are currently experiencing or have experienced ANY COVID-19 symptoms listed above within the past 14 days.

I agree to cancel or reschedule my appointment if I, as well as any household member, has been diagnosed with COVID-19 within the past 10 days.

I agree to cancel or reschedule my appointment if I, as well as any household member, is currently pending COVID-19 test results.

By signing below, I agree to each statement above and release Lovdahl Salon and Studio LLC, Mindful Practice LLC, as well as their practitioners and staff, from any and all liability for exposure or harm due to COVID-19 or any other contagion.

I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

Additionally, By signing below, I confirm that I have reviewed, understood, and signed this form on the same day of my scheduled appointment at Mindful Practice LLC.


First Client's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Client's 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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle 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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