Hello, lovely clients! Because I am at a relatively high risk of covid complications, before we can proceed with rescheduling, I need you to fill out this form. Please be honest! I am also more than happy to provide you with any information about my own personal social distancing practices to help you feel more comfortable.
I promise I will honor all deposits, gift certificates, and appointments as quickly as I am safely able. If you do not want to disclose this information, I totally understand, but will be unable to book you at this time.
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Name (Please write your first & last name in the "first name" box and your email address in the "last name" box! This site won't let me have more than five fields.)
Have you (check all that apply):
Flown on an airplane recently
Visited a hospital
Had contact with a person who tested positive for COVID
None of the above
Please indicate whether your appointment was canceled due to COVID, you were on a waitlist, or you purchased a gift certificate around the holidays. Additionally, what is your occupation? If it puts you at any legal risk to disclose your occupation, please disregard that part of the question!
What is your level of occupational exposure?
None (working from home entirely/unemployed)
Some exposure (to coworkers, but not to the public)
Moderate exposure (customer service, but not a high-risk population)
High exposure (working in medical field or field that requires direct contact)
Describe your social distancing practices & risk tolerance! For example, I am not going to public places (such as restaurants, bars, or stores) except for necessities (groceries etc), I only see friends outdoors & always masked if at less than 6ft (mostly masked even when further apart), and am limiting my social interactions drastically even in these contexts.
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