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 are a close Contact, Even if fully Vaccinated we would ask that you kindly don’t attend an appointment for at least 2 weeks to protect all staff and clients. Full name * E-mail * Phone * Address 1 * Address 2 Town/City * Eircode * 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 been named as a close contact of some one in the last 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.* Submit