Covid-19 Pretreatment form Covid-19 Declaration form To ensure the Safety & Health of all clients interacting with Luxe Salon & Academy, you must complete this declaration form below prior to entering the clinic or on arrival at the clinic. If you indicate to us that you have symptoms of COVID-19 OR you have been abroad in the last 14 days with exception to Northern Ireland you will be required to either restrict your movements or self-isolate. Where this is the case, you are prohibited from entering the clinic and are advised to seek professional medical help/assistance in line with HSE Guidelines. Full name * E-mail * Phone * Address 1 * Address 2 Town/City * Eircode * Have you visited any countries outside Ireland excluding Northern Ireland? * Yes No Are you suffering any flu-like symptoms? Yes No Are you experiencing any difficulty in breathing or shortness of breath? Yes No Are you experiencing any fever/temperature symptoms? Yes No Did you consult a Doctor or other medical practitioner? Yes No Have you been in contact with someone who is confirmed to have COVID-19 or has visited an affected region in the past 14 days?* Yes No How are you feeling health wise?* Well Unwell I hereby declare that the information provided is true and correct to the best of my knowledge.* By using this form you agree with the storage and handling of your data by this website.* If you are human, leave this field blank. Submit
