Hair Questionnaire

Please note that all documents should be routed and approved through your legal counsel if you choose to use.

RELEASE OF LIABILITY AND AGREEMENT NOT TO SUE, INDEMNIFICATION, HOLD HARMLESS, LIMITATION OF WARRANTY

We all know that these are uncertain times. The risks of COVID-19 are not well understood and there is controversy among the experts on how the virus can spread and difficulty in scientifically determining whether anyone has the virus at any moment in time.

In consideration for providing haircuts and color, by signing below you agree to accept all responsibility for the risk that you may contract COVID-19. While we are taking your safety and that of our staff very seriously, by employing new safety and sanitation initiatives, we cannot guarantee that any of these measures will completely protect you from contracting COVID-19.

I agree that if I take any steps to make a claim for damages against PuraVida, its agents, employees or any other released parties arising out of my receipt of haircut and color services during my visit to PuraVida’s facilities, I shall be obligated to pay all attorneys’ fees and costs incurred as a result of such claim.

I acknowledge that I can go elsewhere to have my hair cut and colored, and I acknowledge that PuraVida is not the only hair salon where I can have my hair cut and colored. By signing this Agreement, I acknowledge that I am free to go to other salons who may not require my agreement to accept responsibility for contracting COVID-19. I chose to have a haircut and color services performed at PuraVida today.

Part 2: Government 14 Day Health Questionnaire

1. Have you had a COVID vaccination? YesNo

2. Have you been in close contact the past 14 days with a person known to have COVID? YesNo

3. Do you currently have fever or lower respiratory symptoms such as a cough or shortness of breath? YesNo

Part 3: Basic Information

Part 4: Hair Information

Have you ever suffered from hair loss? YesNo

Do you suffer from psoriasis on the scalp? YesNo

Do you suffer from eczema to the scalp? YesNo

Do you have a sensitive scalp? YesNo

Do you have any known allergies? YesNo

Is your hair currently colored? YesNo

Do you currently have hair extensions in? YesNo

Are you looking to make a major change to your hair? YesNo

How would you describe your hair? FineMediumThickVery Thick

Hair is: CurlyWavyStraightCoils

Length: Short (above the shoulder)Medium (below the shoulder)Long (mid back)

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.