Please fill out the form below: Name First Last Please check each of the boxes below saying that you agree to the following* I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 14 days. I affirm that I, as well as all household members, have not had body aches, chills, headaches or loss of smell within the past 14 days I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days. I understand that Southern Curl Inc and my service provider cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. Date* MM slash DD slash YYYY Signature* Δ
