Consent for Treatment

COVID-19 Information & Liability Waiver
Client Name:
Date:

Month Day Year
Date
1. Have you had a fever in the last 24 hours of 100.0 F or above?

Yes No
2. Do you now, or have you recently had any respiratory or flu symptoms, difficulty of breathing, shortness of breath, cough?

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
4. Have you traveled to an area where Coronavirus has been identified?

Yes No
5. If yes, was travel in the last 14 days international, to an area with sustained community transmission?

Yes No
6. Do you reside in a community where community-based spread of COVID-19 is occuring?

Yes No
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit 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 esthetics and massage involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. Skin Care By Tracie has the right to refuse service(s) if any questions answered above put others at risk, me rejecting to a temperature screening or not having a mask (state requirement). By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, 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:

Clear
Date

Month Day Year
Date
Parent or Guardian Signature (in case of a minor):

Clear
Date

Month Day Year
Date
member Associated Skin Care Professionals
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Should be Empty:

Consent for Treatment

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