Name *

First Name

Last Name

Phone *

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I acknowledge the contagious nature of COVID-19 and that the province and many other public health authorities still recommend practicing social distancing. *

Yes.

No.

I further acknowledge that Black Eleven has put in place preventative measures to reduce the spread of COVID-19. *

Yes.

No.

I further acknowledge that Black Eleven cannot guarantee that I will not become infected with COVID-19. *

Yes.

No.

I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, shop staff, other shop clients and their families. *

Yes.

No.

I voluntarily seek services provided by Black Eleven and acknowledge that I am increasing my risk to exposure to COVID-19. *

Yes.

No.

I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. *

Yes.

No.

I attest that I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. *

Yes.

No.

I attest that I have not been instructed to self isolate by Public Health.

Yes.

No.