Ruby and Clover Hairdressing

Covid-19 Consent Form

First Name_________________________________________________

Last Name__________________________________________________

Date of Birth          /        /

Phone Number______________________________________________


Street Address______________________________________________



I knowingly and willingly consent to have cosmetology services performed at Ruby and Clover hairdressing during the COVID-19 pandemic.  Please circle your answer

YES          NO

I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in the virus testing.  Please circle your answer

YES          NO

I have traveled within or outside the United States by airline bus or train in the past 14 days. Please circle your answer.

YES          NO

Please circle any of the following symptoms of COVID-19 that you are currently experiencing or have experienced in the last 14 days.


Shortness of breath     

Dry cough     

Runny nose     



Body aches     

Loss of taste or smell    

None of the above


To prevent the spread of this contagious virus and help protect myself and others.  I agree to wear a mask covering my nose and mouth while on the premise of Ruby and Clover hairdressing.  Please circle your answer

YES          NO


I have willingly provided the information above.



Temperature (Will be taken at the salon) _________________________

Temperature take by____________________________________________