50 Eucalyptus Blvd Canning Vale Perth WA 6155 AU

Lovely Lashes and Beauty

Eyelash Extensions, Lash Lifts, Waxing, Brow Lamination, Henna Brows & Eyelash Extension Training

COVID-19  PRE-ENTRY CONSULTATION FORM



It is required by Lovely Lashes and Beauty and also some Government regulations, that you fill out this form and email it back to me PRIOR to your appointment.


- When you come to your appointment, please wear a mask that covers from the bridge of your nose to below  your chin (supplied if unavailable).

- You will be required to sanitize hands upon arrival.

- Please do not bring anyone else with you to your appointment.

- Only 1 person per treatment room. If you tend to get chilly during your lash appointment, please bring your own blanket.


PLEASE COMPLETE THE BELOW


FULLNAME:


ADDRESS:


EMAIL ADDRESS:


CONTACT PHONE NUMBER:


DATE & TIME OF YOUR APPOINTMENT:


PLEASE ANSWER YES OR NO TO THE FOLLOWING QUESTIONS:


1.Have you been in contact with a person with a confirmed case of COVID-19? _____________


2. Have you had any of the following symptoms in the past 14 days?

Fever? _____________

Dry cough? _____________

Extreme tiredness? _____________

Difficulty breathing or shortness of breath? _____________

Chest pain or pressure? _____________

Loss of speech or movement? _____________


3. Have you been in contact with anyone with any of the following symptoms?

Fever? ____________

Dry cough? _____________

Extreme tiredness? _____________

Difficulty breathing or shortness of breath? _____________

Chest pain or pressure? _____________

Loss of speech or movement? _____________


4. Have you travelled overseas in the last 14 days? (Per the Commonwealth Government instructions, you must self-isolate for 14 days after returning from overseas.) _____________


5. Have you been in contact with any persons who have travelled from overseas in the past 14 days? ____


6. Have you been in contact with any person who cares for and/or treats confirmed or suspected COVID19 cases? _____________


When completing this Pre-Entry Consultation Form, you have acknowledged your responsibilities in managing your own personal health in relation to COVID-19 and confirm that all of the above information is true and correct.


Signed:


Type full name in capital letters when signature is not available digitally.

Date:

IF YOU ANSWERED YES TO ANY OF THE ABOVE, UNFORTUNATELY I CAN NOT SERVICE YOU UNTIL FURTHER NOTICE