COVID-19 INFORMATION & LIABILITY WAIVER

First Name

Last Name

Date of Birth

Do you now, or have you recently had any repiratory or flu symptoms, sore throat, or shortness of breath?

Yes

Have you had a fever in the last 24 hours of 100 degrees or above?

Yes

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes

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 bean 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.

Type Name

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!