Covid/Monkeypox Pre-Appointment Screening

Covid/Monkeypox Pre-Appointment Screening

*Signature Required Prior to Every Scheduled Appointment*
Date of Appointment *

Month Day Year
Date Hour Minutes AM/PM Option
Due to the outbreak of the novel Coronavirus (COVID-19) and the current state of emergency of Monkeypox (Poxvirus), Lucero Artistry is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the New York Department of Professional and Occupational Regulation guidance.

For the safety of staff and our clients, we reserve the right to cancel or reschedule services that may pose a health risk. Please fill the following form completely before your appointment.

Symptoms of COVID-19 include but not limited to:
- Fever
- Fatigue / Body Aches
- Dry Cough
- Congestion
- Runny Nose
- Chills
- Difficulty Breathing
- Loss of Taste or Smell
Symptoms of Monkeypox include but not limited to:
- Fever
- Headaches / Body Aches
- Swollen Lymph Nodes
- Rash
- Pimple-like blisters
- Lesions
I agree to the following: *

I affirm that I, as well as all household members, do not currently have, nor have experienced and of the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 or Monkeypox WITHIN THE PAST 14 DAYS. I affirm that I, have not been within 6 feet of or live with a person diagnosed with COVID-19 or Monkeypox WITHIN THE PAST 14 DAYS. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 or Monkeypox infections WITHIN THE PAST 14 DAYS. I understand that Aida Lucero and Lucero Artistry cannot be held liable for any exposure to the COVID-19 or Monkeypox virus caused by misinformation on this form or the health history provided by each client.
Lucero Artistry is following these enhanced procedures to prevent the spread of COVID-19:
- There will be a limited amount of clients that will be attended to in a day
- Additional time included between appointments to prevent client contact with each other
- No guests will be allowed to appointments until further notice
- Clients are encouraged to use hand sanitizer or wash hands upon arrival
- Your makeup artist will thoroughly wash and sanitize hands before and after each appointment
- Your makeup artist will wear a clean mask for each appointment
- All skincare product bottles used during treatment will be placed on the trolley for disinfection and disposable items will be used and discarded when possible
- All surfaces will be wiped thoroughly with disinfectant before and after each client according to the manufacturer's directions
WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against
Lucero Artistry and its owners, officers, directors, managers, officials, trustees, agents, employees, or
other representatives in connection with exposure, infection, and/or spread of COVID-19 or Monkeypox related to utilizing Lucero Artistry’s services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.

By signing below, I agree to each statement above and release Aida Lucero and Lucero Artistry from any and all liability for the unintentional exposure or harm due to COVID-19 or Monkeypox.

I understand and agree that the law of the State of NY will apply to this contract.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE,
AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING
LIABILITY AS DESCRIBED ABOVE:

Aida Lucero agrees to abide by these standards and affirms the same.
Name *

First Name Last Name
Email *
example@example.com
Date *

Month Day Year
Date
Signature *

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