Due to COVID-19, we are taking extra precautions with each client and have improved our sanitation and disinfecting practices. Please complete the following and sign below.

I confirm that I, nor anyone in my household have any of the following symptoms of COVID-19 listed below, nor have had any of the following symptoms in the past 14 days:

FeverChillsCoughShortness of breathDifficulty breathingFatigueMuscle achesBody achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrhea

To the best of my knowledge, neither I nor anyone in my household has been in contact with anyone who has tested positive for COVID-19.

I verify that neither I nor anyone in my household has traveled outside the United States in the past 14 days.

I understand that the CDC recommends social distancing of at least 6 feet, and this is not possible with the service I am receiving today.