COVID-19 Information and Liability Waiver


Client Name: ____________

Date: _________

     1. Have you had a fever in the last 24 hours of 100°F or above? Yes   No

  1. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? Yes No
  2. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has corona virus type symptoms? Yes No

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 corona virus. 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.

Client Signature: _______________________________Date___________________________

Parent or Guardian Signature (in case of a minor): ________________________________ Date___________________________