COVID-19 Information & Liability Waiver
Due to the 2019-2020 outbreak of the novel Coronavirus, Covid-19, I am taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.
Email address *
Name *
First and Last
Phone Number *
Symptoms of Covid-19 Include:
I understand the above symptoms and affirm that I, as well as anyone that I have been in contact with, do not currently have, nor have experienced the symptoms listed above within the last 14 days. *
Symptoms Include: Fever, Cough, Shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell
Have you had a fever in the last 24 hours of 100°F or above? *
I affirm that I, as well as all household members, have not been diagnosed with Covid-19 within the last 30 days *
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.
Consent for Treatment
I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
PLEASE TYPE YOUR FULL NAME IN ALL CAPITAL LETTERS TO INDICATE YOUR SIGNATURE: *
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