Client Health Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

First and last name *

Phone number *

This waiver must be filled PRIOR TO EACH VISIT.

PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT:

I agree to follow the City of Chicago’s travel order which states that: Anyone traveling from a state on the Orange list is directed to obtain a negative COVID-19 test result no more than 72 hours prior to arrival in Chicago or quarantine for a 10-day period (or the duration of their time in Chicago, whichever is shorter).

I agree

I disagree

Clear selection

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks. *

I agree

I disagree

I do not have a cough, fever, chills, shortness of breath or loss of taste or smell. *

I agree

I disagree

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact Painless Waxing Boutique. *

Yes

I will follow all posted salon rules to keep myself, my esthetician and those around me safe. *

Yes

I agree not to hold Painless Waxing Boutique and my technician/service provider liable for my exposure to the COVID-19 or any other viral disease or other disease or disorders. *

Yes

Please sign to certify your answers by typing your name below. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this agreement. By selecting 'submit' using any device, means or action, you are signing this agreement electronically and you consent to the legally binding terms and conditions of this agreement. **PLEASE FILL THIS FORM OUT PRIOR TO EACH VISIT.** *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms