COVID-19 Information & Liability Waiver
Name:__________________________
Date:___________________________
If you are experiencing a fever, cough, or sore throat, have been to a COVID-19 impacted
area, or have been in close contact with a person infected with COVID-19, we ask that you please reschedule your appointment for 14 days past the date of contact or until you are asymptomatic. I will be happy to work with you to schedule another appointment as
soon as you are ready to come back. There is no cancelation fee.
COVID-19 Information
1. Have you had a fever in the last 48 hours of 100°F or above?
Yes__ No__
2. Do you now, or have you recently had, any respiratory or flu symptoms,
sore throat, or shortness of breath?
Yes__ No__
3. Have you been in contact with anyone in the last 14 days who has been
diagnosed with COVID-19 or has coronavirus-type symptoms?
Yes__ No__
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and extensive sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus.
However, these best practices still offer no guarantee regarding your potential risk of being infected.
Consent for Treatment
I understand that, because electrolysis involves maintained touch and close physical proximity over an extended period, 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 currently. 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:___________________________
If you are experiencing a fever, cough, or sore throat, have been to a COVID-19 impacted
area, or have been in close contact with a person infected with COVID-19, we ask that you please reschedule your appointment for 14 days past the date of contact or until you are asymptomatic. I will be happy to work with you to schedule another appointment as
soon as you are ready to come back. There is no cancelation fee.
COVID-19 Information
1. Have you had a fever in the last 48 hours of 100°F or above?
Yes__ No__
2. Do you now, or have you recently had, any respiratory or flu symptoms,
sore throat, or shortness of breath?
Yes__ No__
3. Have you been in contact with anyone in the last 14 days who has been
diagnosed with COVID-19 or has coronavirus-type symptoms?
Yes__ No__
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and extensive sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus.
However, these best practices still offer no guarantee regarding your potential risk of being infected.
Consent for Treatment
I understand that, because electrolysis involves maintained touch and close physical proximity over an extended period, 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 currently. 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): ___________________
