Ageless Perfection Skin Care Studio COVID-19 Screening Form & Liability Waiver
By completing and submitting this form, you are knowingly and willingly consenting to having aesthetic/skincare services performed during the COVID-19 Pandemic. You agree to adhere to all safety and sanitation protocols now required by the Ageless Perfection Skin Care Studio.
Email *
First Name *
Last Name *
Contact Cell/Phone Number *
Street Address, City, State Zip *
My Baseline pre-visit temperature must be below 99 degree Fahrenheit to receive a service. I understand my temperature will be taken upon arrival for my appointment and recorded prior to entering building. *
Temperature at appointment (To be completed by RP):
I am aware and understand that I am REQUIRED to wear a mask at all times, unless receiving a facial or facial treatment and will be instructed when to remove. I will be given a mask to wear if I arrive without one. If I refuse to wear mask, I will be instructed to leave. *
I am aware that testing for the COVID-19 is still very limited, the virus has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it . *
I also acknowledge and understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting the virus should it be present. *
I confirm that none of the following COVID-19 signs or symptoms have been present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Diarrhea/Nausea, Muscle Aches/Pain, Headache, Pink Eye, Congestion, Pressure in Chest or been in close contact with a person who is lab confirmed to have COVID-19. IF YOU HAVE HAD ANY OF THESE SYMPTOMS, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the United States. IF YOU HAVE BEEN EXPOSED TO COVID-19, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I affirm that I have not traveled domestically (outside of my state) or internationally (outside of the United States) within the past 14 days. IF YOU HAVE TRAVELED OUTSIDE THE STATE OR INTERNATIONALLY, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I affirm that I have not been in a large crowd (more than 5 people that do not live in the house with me) not wearing a mask and staying 6 ft apart. IF YOU HAVE BEEN IN A CROWD AS DESCRIBED ABOVE, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
Do you suffer from allergies? If yes, explain what are your allergy symptoms. If no, then put "Not Applicable or N/A" below. *
I agree by providing my name below, I am rendering my signature electronically in acknowledgement of the completed statements on this form and that all information is accurate as of the date of this form. Type your name below. *
Date: *
Time: *
A copy of your responses will be emailed to the address you provided.
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