Client Waiver: All guests must submit a new form before each visit *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Cell *

(###)

###

####

In the past 2 weeks have you had or used any of the following? *

New or worsening cough:

Yes

No

*

Fever:

Yes

No

*

Contact with someone who tested positive for COVID-19:

Yes

No

*

Accutane, Retin -A or Retinol:

Yes

No

*

Chemical peels or facials:

Yes

No

*

Tanning bed or direct sun exposure, causing irritation, a burn, or tinea versicolor (sun allergy):

Yes

No