Coronavirus Liability Release Form
Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices.

Symptoms of Covid-19 include, but are not limited to;
Fever
Fatigue
Dry Cough
Loss of Taste
Loss of Sense of Smell
Muscle Pain
Difficulty Breathing
Chills
Sore Throat
Today's Date *
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Guest Name *
Guest Phone number *
Guest Email
Guest Temperature
Have you had a fever or chills within the past 14-days? *
Do you have a cough or have had a cough within the past 14-days? *
Have you had shortness of breath within the past 14-days? *
Have you been in contact with anyone experiencing flu-like symptoms in the past 14-days? *
Have you tested positive for Covid-19 within the past 14-days?
Clear selection
Please review the following statements
- I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced any of the symptoms listed above within the last 14 days.

-I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days.

-I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

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

-I understand that this business and my technician cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history by each client.
Please sign below
By signing below, I agree to each above statement and release the technician and business from any and all liability for the unintentional exposure or harm due to COVID-19.

Your technician and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
Signature of Guest (or Guardian for Guests 18 & under)
Type full name below
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