WILLIAMSBURG BEAUTY SPA

WILLIAMSBURG BEAUTY SPA

COVID-19 Information and Consent Form
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date:*

MonthDayYear
Date
Have you had any fever in the last 24 hours of 100°F or above?*

YESNO
In the last 14 days have you had any respiratory or flu symptoms, sore throat or shortness of breath?*

YESNO
Have you been in contact with anyone in the last 20 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*

YESNO
Credit card required to book all appointments. Enter Card #, Exp Date & Zip Code Below & Service Requesting *
Appointment
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures that Williamsburg Beauty Spa has always adhered to, new preventative measures have been put in place to further reduce the spread of COVID-19. However, these best practices guided by the CDC and other authorities still offer no guarantee regarding your potential risk of being infected.
Consent for Treatment
I understand that, because esthetics 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. 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 and business from any claims related thereto. I give my consent to receive treatment from this practitioner.
Client Signature
Please sign name below:*

Clear
Please verify that you are human*
Should be Empty:

WILLIAMSBURG BEAUTY SPA

Consent for Treatment

Client Signature