This pre-appointment Symptom Survey must be completed prior to your service today. It is critically important that every client and employee is healthy and symptom free. Please complete this brief survey to the best of your ability for the safety and well-being of our clients and staff.

Name

First Name

Last Name

Phone

(###)

###

####

Covid Liability Waiver

Are you currently experiencing any of these symptoms or have you experienced any of these symptoms in the last 24 hours? **If you answer yes to any of these questions, please speak with your artist about rescheduling your appointment for when you have been symptom free for 60 days.

Has at least 14 day elapsed since your 2nd dose of the COVID-19 vaccine?

IF YOU ARE FULLY VACCINATED, YOU MUST PROVIDE PROOF OF VACCINATION. IF YOU CANNOT PROVIDE PROOF OF FULL VACCINATION OR ANSWERED "NO", YOU ARE REQUIRED TO COMPLETE THE REST OF THIS FORM. IF YOU HAVE BEEN FULLY VACCINATED AND AND CAN PROVIDE PROOF, PLEASE CONTINUE TO THE INITIAL SECTION OF THE FORM (THE LAST 3 BOXES).

Please check box if you're experiencing any of these symptoms

Nausea

Fever

Coughing (not related to allergies)

Shortness of Breath

Extreme Fatigue

Gastrointestinal upset

Sore Throat

Loss of taste of smell

No symptoms

Have you recently tested positive for COVID-19 or are awaiting results?

Yes

If you answered yes to the last question, have you since then had a negative test result?

Yes

Have you been in close contact with someone with a confirmed diagnosis of COVID-19 or is being tested for COVID-19?

Yes

I HAVE ANSWERED ALL THESE QUESTIONS HONESTLY AND TO THE BEST OF MY ABILITY. I UNDERSTAND THAT IF I HAVE MISREPRESENTED MY HEALTH STATUS OR THAT OF MY IMMEDIATE HOUSEHOLD IN ORDER TO GET TATTOOED OR PIERCED, I MAY BE HELD LIABLE IN A COURT OF LAW. Initial Below

I UNDERSTAND THAT INCOGNITO X LLC OR ITS PRACITIONERS CANNOT BE HELD LIABLE FOR ANY EXPOSURE OT THE VIRUS CAUSED BY ANY INFORMATION ON THIS FORM, CHANGING SAFETY RECOMMENDATIONS FROM LOCAL, STATE OR FEDERAL AUTHORITIES OR THE HEALTH HISTORIES PROVIDED BY EACH CLIENT. BY INITIALING BELOW, I AGREE TO THE ABOVE STATEMENTS AND RELEASE INCOGNITO X LLC AND ITS PRACTITIONERS FROM ANY AND ALL LIABILITY FOR THE UNINTENTIONAL EXPOSURE OR HARM CAUSED BY COVID-19.

Contact tracing is a way of slowing the spread of infections by identifying people have been in contact with an infected person. Your contact details will be kept confidential and will only be used in the event of a confirmed infected client who you may have been in contact with. Please initial

Any services for oral piercings, you MUST provide proof of vaccination. Providing proof of vaccination does not omit you from wearing a mask for the duration of your service. Even if you provide proof of vaccination, masks are mandatory for the duration of your service. For the continued health and safety of our guests and artists, please do not bring guests or a plus one with you to your service, unless they are also receiving a service or it is a parent/guardian accompanying a minor.

COVID-19 HEALTH SCREENING