Precautionary Coronavirus (Covid -19) Liability Waiver Release Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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 extreme sanitation and disinfection practices. Please complete the following and sign below.

First Name *

Last Name *

Symptoms of Covid-19 include but are not limited to:

-Fever
-Fatigue
-Dry Cough
-Difficulty Breathing/Shortness of Breath
-Loss of Smell or Taste
-GI Symptoms/Diarrhea/Nausea
-Fever/Sore Throat/Cough

I do understand the above-mentioned symptoms and affirm that I , as well as all household members do not currently have, nor have experienced any of the listed symptoms in the last 30 days. *

Yes

I affirm that I, as well as all household members have not been diagnosed with COVID-19, nor have we knowingly been exposed to anyone, within the last 30 days. *

Yes

I agree that I, as well as all household members have not traveled outside of the country, or to any city outside of my own that has been, or is considered a “hot spot” for COVID-19 within the last 30 days. *

Yes

I understand that Lashes By Lola, nor any other businesses located within Signature Salon Suites, can be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or health history by each client. *

Yes

97.3Client's Temperature Prior to Visit *

Time Temperature Was Taken *

Time

I, and all employees of the facility agree that they abide by these same standards and affirm the same. We also agree that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of Coronavirus/Covid-19 and other communicable conditions.

By providing my name below, I agree to the above statements and release Lola Kelly, Signature Salon Suites, its owners, agents, employees, and heirs from any and all liability and/or claim for illness for the unintentional exposure or harm due to COVID-19. This includes personal injury, harm, or death. *

Joanarrey

YYYY

*Please note that temperature will also be taken prior to appointment and service will not be rendered without use of a face covering.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms