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The Burly Barber LLC

764 W. Broadway Rd. ste#104

Tempe, Az 85282 (480) 295-0914


COVID - 19 Pandemic Barber Service Consent Form


I, ___________________________________________________, knowingly and willingly consent to Barbering Service during the COVID-19 pandemic.


 I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.


Barbering services do not allow for social distancing, as we must be in close proximity to complete the services. Due to the aerosol nature of the COVID-19 virus, it can linger in the air for minutes to sometimes hours. 


  • I understand that due to the frequency of visits of other barbering clients, the characteristics of the virus, and the characteristics of barbering services, that I have an elevated risk of contracting the virus simply by being in the barbershop. 



  • I am aware that if I have underlying health conditions that I am at an increased risk for COVID-19. ________(initial)


  • I hereby release, discharge, and agree to save harmless (The Burly Barber), his/her heirs, legal representatives or assigns, and all persons functioning under his/her permission or authority, or those for whom he/she is functioning, from any liability by virtue, including without limitation any claims for libel, infection, medical care or treatment, or invasion of privacy.  ________(initial)


I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

  • Fever

  • Shortness of breath

  • Dry cough

  • Runny nose

  • Sore throat

  • Loss of taste or smell    ________(initial)


I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has utilized air travel. This social distance protocol is not possible with barbering services. ________(initial)


  • I verify that I have not traveled outside the US in the past 14 days ________(initial)

  • I verify that I have not traveled domestically within the US by commercial airline, bus, or train within the past 14 days ________(initial)


I agree to wear an over the ear style face mask during the entire duration of my visit in the barbershop.________(initial)


I understand that wearing a mask is mandatory during the entire duration of my visit, and that if I did not arrive for my service(s) with an over the ear style mask one will be provided to me for a surcharge of $1.00 ________(initial)


By signing below I consent to the contents of this document, and understand that further protocols may be in place for my protection. This includes, but is not limited to: temperature check and recording before entering the barbershop, or any other additional screening that is under the sole discretion of the operators of this business.


All operations and services (as well as their execution) provided by this business are under the sole discretion of the owners and employees of The Burly Barber. 


Signature _______________________________________________ Date __________ 


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