COVID-19 Risk Informed Consent Form
for Corrective Skincare LA
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name of Esthetician for upcoming visit
*
Please Select
Jennifer Kramer
Hannah Land
Maddie Marcus
Sophie Bull
Not Sure
Name of stylists
*
Jennifer
Kramer
Name of stylists
*
Hannah
Land
Name of stylists
*
Maddie
Marcus
Name of stylists
*
Sophie
Bull
I knowingly and willingly consent to having treatment service(s) during the COVID-19 pandemic.
*
by checking this box I understand and accept this statement.
To prevent the spread of contagious viruses and to help protect each other, I understand that I will be required to follow Corrective Skincare's strict guidelines while in-clinic.
*
by checking this box I understand and accept this statement.
I know that the CDC, OSHA, and the California state board of cosmetology recommend social distancing of at least 6 feet.
*
by checking this box I understand and accept this statement.
I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of our services, that I have elevated the risk of contracting the virus by merely being in the clinic, regardless of safety measures.
*
by checking this box I understand and accept this statement.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing.
*
by checking this box I understand and accept this statement.
I verify that I have not traveled outside the United States In the past 14 days to countries that have been affected by COVID-19.
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TRUE
FALSE
I confirm that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.
*
TRUE
FALSE
In-clinic Temperature Policy
I’m willing to take a temperature check during my visit to Corrective Skincare LA before any services begin, and I agree not to come to the clinic with any of the following symptoms of COVID-19 listed below: fever: temperature above 100.4°F, shortness of breath, loss of sense of taste or smell, dry cough, runny nose, or sore throat.
I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible client experience when visiting Corrective Skincare LA.
*
TRUE
Signature
*
Submit
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