Name *

First Name

Last Name

Phone *

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NEW SALON HEALTH + SAFETY FORM IN RESPONSE TO COVID-19 *

PLEASE READ + MARK EACH BOX BELOW. BY SUBMITTING THIS FORM, YOU CERTIFY THAT YOU HAVE COMPLETELY READ, UNDERSTAND, AND WILL COMPLY WITH THE NEW COVID-19 PROTOCOLS. We understand that there are a lot of changes as we return to the salon and want to express our sincere gratitude for your patience and understanding during these challenging times. The health and well-being of our guests, team and community is of utmost importance to us, as is the continued ability of Art + Autonomy to remain in business and keep our doors open.

I certify that I, or anyone I am in regular close contact with, have not traveled outside of the United States OR been on a plane traveling within the United States in the last 14 days prior to my appointment. (If you have traveled or been on a plane within the 14-day window prior to your appointment, we will be happy to reschedule you at no cost when you have met the 14-day time frame.)

I certify that I, or anyone I am in regular close contact with, have not traveled from the US states on the NYS quarantine list within the last 14 days prior to my appointment. As of 10/22/20 those states are: Alaska, Alabama, Arkansas, Arizona, Colorado, Delaware, Florida, Georgia, Guam, Iowa, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Mississippi, Montana, North Carolina, North Dakota, Nebraska, New Mexico, Nevada, Ohio, Oklahoma, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, West Virginia, and Wyoming.

I, or anyone I am in regular close contact with, have not experienced or shown any symptoms of COVID-19 within the last 14 days prior to my appointment. Symptoms include: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea.

I will wear an ear loop mask (one that ties behind the ears, not the back of the head) and sanitize my hands upon entering the salon. My mask will remain on for the duration of my visit. (If you don’t have a mask, one will be available for purchase.)

I will respect the 6-foot social distancing policy.