Barber Shop Consent and Appointment Form

A form that pairs a brief health screening with appointment scheduling so the barbershop can confirm client consent before service.

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Client Name

Nombre

Apellido

By checking the boxes, you confirm that you agree with the following statements:

I do not have symptoms of a contagious illness I have not been in contact with an infected person I accept the barbershop's health and hygiene policy I consent to receive the service

Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell

Yes No

Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or get infected?

Yes No

Are you living with anyone that is get infected or quarantined due to COVID-19?

Yes No

Appointment Date and Time

Date

Time

Additional Notes

Parent/Guardian Name (if applicable)

Nombre

Apellido

Date

Client/Parent/Guardian Signature

Sign here

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