Stylist Name *

First Name

Last Name

Date *

MM

DD

YYYY

I certify that the following is true and correct. *

I am not feeling ill and have not shown any symptoms of COVID-19 within the last 14 days.

I have not tested positive for COVID-19 within the last 14 days.

I have not been in close contact with anyone known to have or showing signs of COVID-19 within the last 14 days.