Blume Beauty Co. Covid-19 Waiver & Consent for Treatment

Blume Beauty Co. Covid-19 Waiver & Consent for Treatment

Client Full Name:*

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date:*

1. Have you had a fever in the last 24 hours of 100°F or above?*

YESNO

2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*

YESNO

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus*

YESNO

Guests will be required to observe the following policies:

-Masks are required for everyone upon entry to Blume
-Hand sanitizer will be readily available for guests
-Guests with appointments are only permitted to enter the courtyard & studio at their scheduled appointment time.
-Guests may not bring children or friends into the courtyard or studio unless they have a scheduled appointment.
-Guests are not permitted into the salon if they exhibit any symptoms that may be an indicator of any infection (i.e. congestion, runny nose, coughs, fevers, body aches, etc.).
-Guests are asked to reschedule their appointment for 14 days later if they have been around anyone exhibiting symptoms that may be an indicator of any infection (i.e. congestion, runny nose, coughs, fevers, body aches, etc.).
-Arriving to your appointment while exhibiting any symptoms and ignoring any of the above guidelines will lead to refusal of service and a partial payment for services, NO EXCEPTIONS

I understand that 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.

I understand it is my responsibility to inform Amy Miller-Wieczorek immediately if any possible symptoms of Covid-19 arise within 24 hours of any of my appointments.

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. Upon entering the Blume courtyard and studio, 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 Amy Miller-Wieczorek and Blume from any claims related thereto. I give my consent to receive treatment from Amy Miller-Wieczorek.

Client Signature*

Full Name

Date*

Parent or Guardian Signature

Date

Client Treatment Consent & Release

I acknowledge that beauty treatments, the practice of skin care, and the practice of advanced esthetic procedures, including, but not limited to, microneedling, microdermabrasion, waxing, nano infusion, facial toning, permanent cosmetics, body treatments, ionization, microcurrent, tattoo removal, vein treatments, brown spot removal, advanced chemical peels, alkaline wash, scar revision, advanced skin revision, Dermaplaning, Lash Extensions, Keratin Lash Lifts and various other beauty procedures is not an exact science and no specific guaranties can or have been made concerning the outcome. I understand that some clients experience more change and improvement than others. In virtually all cases, multiple treatments are required in order to realize a difference.

I also understand and agree to assume the following risks and hazards which may occur in connection with any particular treatment including but not limited to: unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection, change in skin pigmentation, allergic reaction, muscle damage, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance.

Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability the company and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.

Upon entering the Blume courtyard and studio, I acknowledge that I am aware of the risks involved from receiving treatment and I voluntarily agree to assume those risks, and I release and hold harmless Amy Miller-Wieczorek and Blume from any claims related thereto. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties. I give my consent to receive treatment from Amy Miller-Wieczorek.

Client Signature*

Date*

Model Release:

In consideration for treatment received, I hereby grant permission to the Amy Miller-Wieczorek and Blume Beauty Co. that provided my treatment to use any photographic treatment records for the purposes of clinical and statistical studies, advertising, or promotion without any additional compensation to me.

Client Signature*

Date*

Date