Phone *

Please complete prior to your schedule appointment.

Have you been diagnosed with or suspected of having COVID-19? *

Yes

Have you been tested for COVID-19? *

Yes

Date of Scheduled Appointment *

Have you or your family or close contacts traveled out of the state or internationally in the last 14 days? *

Yes

Have you had an antibody test for COVID-19? *

Yes

Right to Refuse Service *

I acknowledge and understand that Waxing | Suite has the right to refuse service at anytime and for any reason.

Are you currently experiencing symptoms of fever, fatigue, dry cough, shortness of breath, muscle pain, Nausea, Diarrhea, Headache,oss of sense of taste or smell or sore throat? *

Yes

COVID-19 Liability Release *

I understand that it is my right to be serviced by Waxing | Suite. As such, I relinquish Waxing | Suite of any and all liability surrounding the exposure or contraction of COVID-19.

Email: *

Check here to receive email updates

COVID-19 Guidelines *

To prevent the spread of contagious viruses and to help protect our community, I must comply with Waxing | Suite set safety standards at all times to be serviced. This includes but is not limited to the mandatory wear of an face mask for the duration of service.

Notice of Responsibility *

By order of the State of Maryland, I understand that it is my responsibility to notify Waxing | Suite should I become ill within 14 days after service.

Name: *

My signature guarantees that the information provided is accurate and truthful to the best of my knowledge. I understand and comply with the policies and procedures outlined for the service with Waxing | Suite. *

Have you been in contact or been exposed to anyone with COVID-19 in the past 14 days? *

Yes

Thank you!

COVID-19 Intake Form

Date *

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