COVID-19 Pandemic Skin Treatment Consent Form
Maison de Peau, LLC
Name
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First Name
Last Name
Date
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Month
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Day
Year
Date Picker Icon
Name of Skin Therapist
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First Name
I knowingly and willingly consent to receiving skin treatment(s) during the COVID-19 pandemic.
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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 must follow the spa's strict guidelines
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by checking this box I understand and accept this statement.
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I am aware that the CDC, OSHA, and Kentucky State Board of Cosmetology recommend social distancing of at least 6 feet.
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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 skin treatments, that I may have elevated the risk of contracting the virus by merely being in the facility.
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by checking this box I understand and accept this statement.
I understand that 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 given the current testing limitations.
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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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YES
NO
I confirm that I have or have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days
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YES
NO
In-Spa Symptoms Policy
I agree that by showing up for the appointment, I do not exhibit the following symptoms associated with COVID-19: Body temperature of 100 & above, Shortness of breath, Loss of sense, taste or smell, Dry cough, Runny nose & 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 guest experience when visiting Maison de Peau
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Yes
Signature
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