COVID-19 INFECTION CONTROL FORM

Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Email Address*
By checking the boxes, you confirm that you agree with the following statements: *
I am having an injectable treatment (Dermal Fillers) I have been advised not to undergo any Filler treatment for two weeks prior to receiving vaccine or four weeks after. *
Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell *
Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell *
Within the last 14 days, have you been in contact with anyone that has COVID-19 symptoms or is infected? *
Are you living with anyone that is infected or quarantined due to COVID-19? *
DP Aesthetics reserve the right to deny entry if safety is compromised.
I agree not to visit the salon for any of the services provided if I have the symptoms of COVID-19 or have been in contact with anyone that has symptoms of COVID-19.
I acknowledge that the information I have given in this consent form is accurate and complete.
I confirm that I understand and agree to all terms and statements in this form. *
Sign Your Name*
Date*