COVID-19 BK SERVICE CONSENT FORM - Your Name (required) - Your Email (required) - Your Phone number (required) - Your Date of SERVICE (required) - IN-STORE TEMPERATURE POLICY I’m willing to take a temperature check during my visit to the store before the service are started. I confirm that I am not presenting any of the following symptom of COVID_19 listed below: Fever -Temperature: 99 degree or Higher Dry Cough Shortness of breath Chest Pain Headeache Loss of sense of taste smell Runny nose Sore Throat Muscle Pains Diarrhea Nausea/Vomiting. - Have you been in contact with a person with COVID-19, in quarantine, or have symptoms of COVID-19 within the past 14 days. YESNO - I knowingly and willingly consent to have a reflexology treatment during the covid-19 pandemic. By checking this box I understand and accept this statement. - I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of reflexology services, that I have elevated the risk of contracting the virus by merely being in the store. By checking this box I understand and accept this statement. - I know that the CDC,OSHA, AND ARIZONA state board of cosmetology recommend social distancing of at least 6 feet, required to wear mask at all time, and I have to follow the store's strict guidelines. By checking this box I understand and accept this statement. - I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when visiting BANGKOK REFLEXOLOGY. I will not hold the salon responsible if I were contract COVID-19 infection around and during the time of services. YESNO Signature here* [signature* signature-819 cols:500 rows:250 color:FFFFFF] All your personal information is kept confidential and will not be shared with anyone outside of Bangkok Reflexology.
