Updated Chrysalis COVID-19 Liability Release Waiver

COVID-19 Liability Release Waiver

**Signature Required Prior to Every Scheduled Appointment**
Dear Valued Client,

Due to the current outbreak of COVID-19, Chrysalis is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the Texas Department of Professional and Occupational Regulation guidance. These precautions are for your safety and well-being as well as for your service provider(s).
Do you have any of the following respiratory symptoms: (check all that apply)

Fever Sore throat Cough Shortness of breath
Have you recently lost your sense of smell or taste?

Yes No
Have you had any GI symptoms? Diarrhea/Nausea

Yes No
Have you experienced any of these symptoms in the last 14 days?

Yes No
Have you been in contact with anyone who has tested positive for COVID-19 in the past 14 days?

Yes No
Do you wear a mask in public?

Yes No
Are you practicing social distancing?

Yes No
I agree to the following: *

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 14 DAYS. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 14 DAYS. I understand that Chrysalis 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. I will contact Chrysalis if I test positive for COVID-19 within 14 days after my visit.
Chrysalis is following these enhanced procedures to prevent the spread of COVID-19:

• Contactless checkout is available
• Additional time will be included between appointments to prevent client contact with each other
• Guests accompanying those scheduled for services is discouraged
• Each client required to wash or sanitize hands upon arrival
• Your service provider will thoroughly clean their hands prior to performing services and wear nitrile gloves, mask and eye protection during all treatments
• Your service provider will thoroughly clean the treatment room in between clients with hospital-grade disinfectant which effectively kills 99% bacteria
• All products and implements used during treatment will be appropriately and thoroughly sanitized and disinfected. Disposable items will be used when possible and disposed of properly.
• All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each client according to the manufacturer's directions.

By signing below, I agree to each statement above and release Chrysalis from any and all liability for the unintentional exposure or harm due to COVID-19.

Chrysalis agrees to abide by these standards and affirms the same.
Date *

Month Day Year
Date
Name *

First Name Last Name
Signature *

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