Pre Appointment Screening Questionnaire | Ciro's Hair Pavilion

HOME
SERVICES
BRIDAL
TEAM MEMBERS
SHOP
CONTACT
- Salon Policies & Guidelines
- Credit Card Request Form
HOURS
CAREERS
GIFT CARDS
LOG IN
More

Use tab to navigate through the menu items.

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

First Name

Last Name

Cell Number

1. Are you answering for yourself or someone else?

Myself

Spouse/Partner

Child

Parent

Someone else

2. Have you experienced the following symptoms in the last 72 hours? Check all that apply

Fever of over 100.4

Sore throat

Nausea or vomiting

Muscle or body aches

New loss of taste or smell

Cough

Congestion or runny nose

Shortness of breath

None of the above

3. Have you been in close contact with another person who has been diagnosed with or under investigation for COVID-19?

Yes

I don't know

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?

Yes

I don't know

5. In the last 2 weeks have you traveled outside of the State of NJ?

Yes (please list State below)

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.

Credit Card #:

Expiration Date: (MMYY)

Name of cardholder:

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

We all know that these are uncertain times. The risks of COVID-19 are not well understood and there is controversy among the experts on how the virus can spread and difficultly in scientifically determining whether anyone has the virus at any moment in time. In consideration for providing hair services, by signing below you agree to accept all responsibility for the risk that you may contract COVID-19. While we are taking your safety and that of our staff very serious, by employing new safety and sanitation initiatives, we cannot guarantee that any of these measures will completely protect you from contracting COVID-19. I agree that if I take any steps to make a claim for damages against Ciro's Hair Pavilion, its agents, employees or any other released parties arising out of my receipt of hair services during my visit to Ciro’s Hair Pavilion's facilities, I shall be obligated to pay all attorneys’ fees and costs incurred as a result of such claim.

I have read & agree to the above salon policies & guidelines to keep myself, salon staff and others safeView our guidelines & policies here

Your Signature