Intake Form | Salon Bellus

469-892-6749

First Name

Last Name

Email

Phone

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

Yes

No

Have you experienced any cold or Flu-like symptoms in the last 14 days (Fever, cough, sore throat, respiratory illness, difficulty breathing)?

Yes

No

I knowingly and willingly consent to have hair treatment during the COVID-19 pandemic.

Yes

No

To prevent the spread of COVID-19, I understand I will be required to follow the salon's strict sanitation and safety guidelines.

Yes

No

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious.

Yes

No

Your Signature

If you have colored your hair at home, please describe what was used:

Thanks for submitting!

469-892-6749