Angel's Touch Skincare and wellness COVID-19 Questionnaire and important appointment information

Angel's Touch Skincare and wellness COVID-19 Questionnaire and important appointment information

**Please complete for prior to appointment time. Signature Required Prior to Every Scheduled Appointment**
Name

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Appointment
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Anel's Touch is taking extra precautions with the care of every guest to include health history review and enhanced sanitation/disinfection procedures in accordance with the Maryland Department of Health, MD Board of Cosmetology & Massage Therapy, as well as the CDC and OSHA recommendations.

Symptoms of COVID-19 include:
- Fever
- Fatique
- Dry Cough
- Difficulty Breathing
I agree to the following: *

I understand the above symptoms and affirm that I do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS. I affirm that I have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS. I understand that Angel's Touch Skincare and Wellness cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.
Angel's Touch is following these enhanced procedures to prevent the spread of COVID-19:
- Credit card will be held on file to reserve appointment and assist in contactless checkout. Should a guest no show or cancel within 24 hours Angel's Touch reserves the right to charge guest credit card for the scheduled service.
- Guests accompaning those scheduled for services will not be allowed to enter unless an adult accompaning a minor receiving service.
- Each guest will be required to wear a mask.
- Guest will wait and process outside or in car as we are required to close relaxation waiting areas
- All surfaces in treatment rooms, bathrooms, and retail area will be wiped thoroughly with hospital grade disinfectant before and after each guest according to the manufacturer's directions
- Additional time has been included between appointments to prevent guest contact with each other and proper sanitation time.
By signing below I am acknowledging that I understand and agree to the temporary guidelines and procedures in place for receiving services at Anel's Touch Skincare and Wellness.

Angel's Touch Skincare team agrees to abide by these standards and affirms the same.

Pass Medical History __________________________________________

List all Allergies ______________________________________________

Date *

Month Day Year
Date

Signature *

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