COVID-19Risk Acknowledgement Form Name * First Name Last Name Email * Phone * (###) ### #### Have you or any member of your household had any of the symptoms listed above in the past 14 days: * difficulty breathing or shortness of breath chest pain or pressure loss of speech or movement fever dry cough aches and pains sore throat diarrhea conjunctivitis loss of taste or smell a rash on skin, or discolouration of fingers or toes Yes No Have you or any member in your household, been knowingly exposed to someone diagnosed with COVID-19 in the past 14 days? * Yes No I understand that Wild Vine Beauty and its salon professionals have implemented recommended disinfection protocols, and despite this, the risk of COVID-19 infection still exists. I am attending my appointment and I acknowledge that risk. * I understand and acknowledge that I am relinquishing any liability from Wild Vine Beauty, including the right to sue or seek any compensation should damages arise from COVID-19 exposure. Submission of this form and attending my appointment constitutes a digital signature with which I am affirming that my answers have been true and complete to the best of my knowledge. I understand that if my circumstances change or symptoms or exposure occurs between completion of this form and the time of the appointment, I should cancel the appointment immediately and I will not be penalized for this cancellation. I agree to the above risk acknowledgement and liability waiver and agree to comply with all instructions as provided. Thank you!
