COVID-19 BK SERVICE CONSENT FORM

– Your Name (required)
[text* your-name]

– Your Email (required)
[email* email-731]

– Your Phone number (required)
[tel* tel-378 “Phone number”]

– Your Date of SERVICE (required)
[text* text-499 placeholder “mm/dd/yyyy”]

– 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.
[checkbox* checkbox-143 “YES” “NO”]

– I knowingly and willingly consent to have a reflexology treatment during the covid-19 pandemic.
[checkbox* checkbox-596 “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.
[checkbox* checkbox-596 “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.
[checkbox* checkbox-206 “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.
[checkbox* checkbox-83 “YES” “NO”]

Signature here*
[signature* signature-819 cols:500 rows:250 color:FFFFFF]

[submit “Send to BK Reflexology”]

All your personal information is kept confidential and will not be shared with anyone outside of Bangkok Reflexology.
1
“[your-name]” “[tel-378]” COVID-19 BK SERVICE CONSENT FORM
[_site_title]
bkreflex2016@gmail.com
COVID-19 BK SERVICE CONSENT FORM:
-Customer Name: [your-name]
-Customer Phone: [tel-378]
-Customer Email: [email-731]
-Your Date of SERVICE [text-499]
-Have you been in contact with a person with COVID-19, in quarantine, or have symptoms of COVID-19 within the past 14 days.: [checkbox-143]
– I knowingly and willingly consent to have a reflexology treatment during the covid-19 pandemic.
[checkbox-596]
– 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.
[checkbox-596]
– 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.
[checkbox-206]
– 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.
[checkbox-83]

-Customer Signature [signature-819]
————-
Bangkok Reflexology (http://bkreflex.com)
Reply-To: bkreflex2016@gmail.com

[_site_title] “[your-subject]”
[_site_title]
[your-email]
Message Body:
[your-message]

—
This e-mail was sent from a contact form on [_site_title] ([_site_url])
Reply-To: [_site_admin_email]

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