COVID19 Client Pre-Appointment ScreeningClient Information and Liability Release Form Client Information Please be honest when filling out this form. If you do not fully disclose information asked, any services I may provide based on the information you give me could result in an unfavourable outcome, which I will not be liable for. The information you provide is in confidence and will not be shared with outside parties. Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, healthy history review, as well as increased sanitation and disinfecting practices. Please complete the following and sign below. Symptoms of COVID-19 include: • Fever • Chills/Shakes • Difficulty Breathing • Dry Cough • Sore Throat • Sneezing • Skin Rashes • Sudden loss of taste or smellPatient Full Name *Date / Time *Date of Birth *Email *I understand the above symptoms and affirm that I, as well as my household members, DO NOT currently have, nor have experienced the symptoms listed above within the last 21 days. *YesNoI affirm that I, as well as the household members, have NOT been diagnosed with COVID-19 within the last 30 days. *YesNoI affirm that I, as well as all household members, have NOT knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. *YesNoI affirm that I, as well as all household members, have NOT traveled outside of the country, or to any city outside of our own that has not been considered a “hot spot” for COVID-19 infections within the last 30 days. *YesNoI understand that due to other clients visiting the clinic for treatments and due to the characteristics of the virus, I have an elevated risk of contracting the virus simply by being in the clinic. *YesNoI understand the Provincial Health Authority recommends physical distancing of at least 6 feet, and this is not possible when seeking beauty treatments. *YesNoI understand that this business and my medical esthetician cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. *YesNoI understand that this clinic screens all clients and team members for possible COVID-19 per the current guidelines. However, carriers of the virus may be completely asymptomatic as the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. Some may never develop severe symptoms. While this clinic strictly adheres to the CDC, Federal and Provincial Health Authority standards as they currently exist, COVID-19 is a new highly contagious pathogen that can be transmitted to and from the spa, health, and wellness professionals even under strictly followed standards. This virus can be spread through droplets or contact. *YesNoBy signing below I agree to each above statement and release the medical esthetician and business from any and all liability for the unintentional exposure or harm due to COVID-19. Your medical esthetician and all team members of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions. * Do you have any additional comments or health issues CommentSubmit
