Precautionary Coronavirus Liability Release Form

Precautionary Coronavirus Liability Release Form
Date*
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Name of Client
First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Date of Birth*
MonthDayYear
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Age
Gender
MaleFemale
Due to the outbreak of the novel COVID-19, Clean Slate Spa is taking extra precautions with the intake of each client, health history review as well as sanitation and disinfecting practices.
Symptoms of COVID-19:
- Fever
- Fatigue
- Dry Cough
- Difficulty Breathing
- Muscle Aches
- Sore Throat
- Loss of Taste and Smell
Service Scheduled:
I agree to the following:
I understand the above symptoms and affirm that I, as well as those in my household, do not currently have, nor have experienced the symptoms above within the last 14 days.I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days.I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.I affirm that I, as well as those in my household, have not traveled outside of the U.S. or to any city that is 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 Clean Slate Spa and my esthetician cannot be held liable for any exposure to the COVID-19 virus or by any other contagion caused by misinformation on this form or the health history provided by each client.
I have been oriented of the following for this appointment (all must be checked):
Upon entering the building, please use the restroom to wash your hands prior to entering the suite.Please use hand sanitizer located outside the suite door prior to entering.A disposable mask will be provided to you. (You are more than welcome to provide your own face covering.)No additional persons, including family, friends, children will be allowed during your appointment. This includes waiting areas and treatment rooms.You may be asked to remain in your vehicle instead of congregating in the waiting area prior to your appointment.
By signing below, I agree to each of the above statements and release Clean Slate Spa and its owner from any and all liability for the unintentional exposure of or harm from COVID-19.
Clean Slate Spa agrees they will also abide by these same standards and affirm the same. Clean Slate Spa also affirms the continuous improvement and expanded santitation protocols to fight the spread of COVID-19 and other communicable diseases.
Date Signed
MonthDayYear
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Signature of Clean Slate Spa Client
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