I understand that the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show the symptoms and may still be contagious.
 
I understand that physical distancing of 6 feet may not be possible while in the clinic receiving treatments.

I understand that I must sanitize my hands before entering the clinic. Hard surfaces such as door handles, Ipads, payment terminals, and countertops will be wiped after each client.
 
I confirm that I am not currently positive for novel coronavirus.
 
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.
 
I verify that I have not returned to Canada from any country outside of the Canada, whether by car, air, bus or train in the past 14 days.
 
I verify that I have not been identified as a contact of someone who has test positive for the novel coronavirus or been asked to self-isolate by The Canadian Department of Health, or any other government agency.
 
I confirm that I am not presenting with any of the following symptoms of COVID-19 indentified by the CDC.    

            Fever > 38C, or 100F, chills or body aches
            Cough
            Sore Throat
            Shortness of breath
            Difficulty breathing
            Flu-like symptoms
            Runny Nose
            Loss of smell or taste
 
I confirm that I am not in high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy or over the age of 65.

I understand that for the safety of everyone, my temperature will be check before the services are started.  

I understand that I may be unable to proceed with services at Jupiter Medical Aesthetics if they are deemed unsafe to myself or a staff member

I UNDERSTAND I MAY NOT BRING CHILDREN OR ANYONE ELSE WHO DOES NOT HAVE AN APPOINTMENT INTO THE CLINIC.
 
I understand the staff Jupiter Medical Aesthetics will do everything possible to minimize the spread of COVID – 19, but will not hold them responsible should I contract the COVID – 19.
 
I will immediately notify the Clinic if I contract the virus within two weeks following my visit.
 
I verify that the information I have provided on this form is truthful and accurate.