Wellness Screen & Consent

Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

My body temperature is lower than 99.5°F/ 37.5°C

Are you experiencing any flu/ COVID symptoms?

Yes

Do you consent to have a picture taken of your henna after service?

Do you give your consent to post pictures of service on business social media accounts (e.g: yelp, instagram, company website, etc.) ?

I ACKNOWLEDGE that with the transmission of any communicable disease such as cold or flu, you may be exposed to COVID-19, also known as the "Corona virus" at any time or in any place. Despite these measures, due to the nature of the service, it is NOT possible to maintain social distancing at all times between a client and artist. Exposure to communicable disease is unlikely but possible.

Jagua temporary tattoo is a citrus fruit and may cause irritation or rash if you are allergic to pineapple, kiwi, or any citrus fruit. Do you consent to have Jagua application knowing that this may cause irritation 1-2 weeks after application?

Date

Initials

I confirm that the information given in this form is true

I accept terms & conditions

Thanks for submitting!