Pre Appointment Screening Form

Required prior to arriving for your appointment, please take the time to fill out the information below. This is required by State Law 24 hours prior to appointment and again upon arrival.

 

*Instructions: Please make sure to finish this form to the end, sign and submit. Thank you.

Any questions or issues please call 201-791-6414 and we can screen you by phone

1. Are you answering for yourself or someone else?
2. Have you experienced the following symptoms in the last 72 hours? Check all that apply
3. Have you been in close contact with another person who has been diagnosed with or under investigation for COVID-19?
4. In the last two weeks have you visited, worked or volunteered in a hospital, emergency room, clinic, medical office, long-term care facility or nursing home, ambulance service, first responder services, or any health care setting or taken care of patients as a student or part of your work?
5. In the last 2 weeks have you traveled outside of the State of NJ?

Credit Card Info

(*required for all new clients for any appointment type and for existing clients that have a chemical and/or color service appointment. This information is used for your client file only and your credit card will not be processed. Please visit our Guidelines & Policies Page for more details.

RELEASE OF LIABILITY AND AGREEMENT NOT TO SUE, INDEMNIFICATION, HOLD HARMLESS, LIMITATION OF WARRANTY