Customer Form

Name *

Email Address *

Phone *

Street Address *

City

County

Eircode

Have you received a vaccine for COVID-19? *YesNoPlease only tick Yes if you have received both doses (where applicable) of the vaccine.

Have you previously tested positive for COVID-19? *YesNo

Date of Positive Test *

Have you had a recent onset of any of the following symptoms in the last 14 days; dry cough, tiredness, shortness of breath, loss of taste or smell, aches and pains, headache, sore throat, nasal congestion, red eyes, diarrhoea, or a skin rash? *YesNo

Have you been in contact with a confirmed or probable case (symptomatic) of COVID-19 in the last 14 days? *YesNoThis includes household contacts – if someone you live with is symptomatic

Have you travelled abroad in the last 14 days (this includes to the UK)? *YesNo

Have you ever had an allergic reaction to any hair colourant/keratin smoothing product? *YesNo

Do you have sensitive, itchy, or damaged scalp? *YesNo

If you require your colour/keratin smoothing treatment done immediately, please check the box below to agree that you are willing to go ahead with the treatment without your skin being testedI agree

Tick below if you agree to allowing us to post a photo of you online, including our website, social media pages, and stylist pagesI agree

Signature *

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Visage Hair Design, 8 Market Street, Galway City. H91 VW92

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