Consent Form - NYC Massage and Spa

Please take a moment to complete our consent form.
By submitting the form below you agree to knowingly and willingly consenting to have hair/skin/body service during the COVID-19 pandemic.
We reserve the right to refuse service if this form is not submitted. Thank you.

First Name*

Last Name*

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. It is impossible to determine who has it and who does not, given the current limits in virus testing. *

Yes

I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of hair services, that I have an elevated risk of contracting the virus simply by being in the salon.*

Yes

I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below:*

• Temperature above 98.7 degrees
• Shortness of breath
• Loss of sense of taste or smell
• Dry cough
• Sore Throat

I Am Not Presenting Symptoms

I confirm that I have not been around anyone with these symptoms in the past 14 days.*

Yes

I do not live with anyone who is sick or quarantined.*

I Do Not

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.*

Yes

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And I understand that the CDC, OSHA and Texas Board of Cosmetology and Barbers recommend social distancing of at least 6 feet.*

Yes

I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.*

Yes

I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.*

Yes

Date *

Please enter today's date.

MM*

DD*

YYYY*

Digital Signature*

Please type your full name below. By typing and submitting, this serves as a Digital Signature and verifies that you fully agree to our safety policy for our services. This digital signature holds the same authority as a handwritten one. Thank you.

This field should be left blank