The Looking Glass Esthetics Studio
Pedicures & Manicures
Dermalogica Skin Treatments
Covid-19 Consent Form
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Risk Acknowledgment Form-Covid-19
Indicates required field
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below: • Temperature above 98.7 degrees • Shortness of breath • Loss of sense of taste or smell • Dry cough • Sore Throat *
I confirm to cancel all appointments at the studio if any symptoms develop, if I am required to self-isolate, or if I knowingly had close contact with someone who is confirmed or suspected of COVID-19.
I confirm that I have not traveled outside of Prince Edward Island in the past 14 days
All personal information will be kept completely confidential by The Looking Glass & shall only be provided if requested by PEI health officials for contact tracing if required.
I understand and agree for the above information to be access by Health officials if required for Covid-19 contact tracing only.
Relaxation esthetics services in the comfort of a quiet, uninterrupted private residential environment located in