Covid-19 Ethos of Annapolis Services Consent Form

Covid-19 Ethos of Annapolis Consent Form

By submitting this form, you agree to have skin, or body services during the pandemic.
Client Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
By checking the boxes, you confirm that you agree with the following statements:

I agree to obey the rules of the spa during my appointment in order to minimize the spread of viruses.I confirm that I have not been diagnosed with COVID-19 in the last 14 days.I verify that I am not waiting for the laboratory test results for COVID-19.I understand that I have a risk of contracting COVID 19 during the service and will not hold Ethos liable for any resulting issues and accept this risk.I will immediately notify Ethos if I contract the virus within two weeks following my visit.
Do you have any of these symptoms? - loss of taste/smell, cough, shortness of breath, high fever, muscle pain, body ache, nausea

YesNo
Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or is infected?

YesNo
Are you living with anyone that is infected or quarantined due to COVID-19?

YesNo
I agree not to visit Ethos of Annapolis for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.
Parent/Guardian Name (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Client/Parent/Guardian Signature

Clear
Should be Empty:

Covid-19 Ethos of Annapolis Consent Form