Covid Screening

Due to the continued rise in COVID-19 cases and based on the CDC Guidelines, service providers are encouraged to screen all clients for signs of the novel coronavirus (COVID-19) symptoms prior to their appointment.

*If you are experiencing any of the COVID-19 symptoms listed below, please cancel your appointment immediately.

Fever Cough

Shortness of Breath

Muscle Pain

High Temperature

Bluish lips or face


Sore Throat


Loss of sense of smell/taste




Runny Nose

Difficulty Breathing

Body Aches




Pain/Pressure in Chest


 ☐I confirm that I am not displaying or currently experiencing any of the COVID-19 symptoms listed above.

☐I understand that carriers of COVID-19 may not show symptoms but may still be contagious.

☐I have NOT tested positive for COVID-19 and am NOT presumptively positive for COVID-19.

☐I have NOT been in a facility or home with confirmed COVID-19 by lab test within the last 14 days.

☐I have NOT traveled outside of the state of Hawaii in the last 14 days. ☐I am NOT currently waiting to receive COVID-19 test results.

☐I confirm that I have not been in contact with persons with confirmed COVID-19 by lab test within the last 14 days.

☐I am acknowledging the potential risk to contract the COVID-19 disease during services provided today and voluntarily agree to accept services and follow all salon protocols included but not limited to:

     • Sanitizing your hands upon entry

     • Avoiding shaking hands and hugging others during your time in The Sustainery Hair Studio

     • Maintaining social distancing and not congregating in any space within the The Sustainery Hair Studio

Please Fill in your Stylists Name Below

By signing below, you pledge to provide only correct and truthful information when completing this screening

Leave this empty:

Sustainery Hair Studio
Signature Certificate
Document name: Covid Screening
Unique Document ID: 49964f945ddf5fab499a4b9f3d33478bf4bd332c
Timestamp Audit
September 11, 2020 10:06 pm HSTCovid Screening Uploaded by Anjalee MIddleton - IP