Form

Name

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

All client must have understood, read and signed this consent form prior to having their treatment at Mi Beauty Clinic.

Please confirm*

I understand the Coronavirus has a long incubation period during which the carriers of the virus may not show any symptoms and may still be contagious.I understand that physical distancing of 2 metres may not be possible while in the clinic receiving services.I understand that I must sanitise my hands on entering the salon.I must wear a mask that covers my mouth and nose while in common areas.I will minimise touching hard surfaces such as door handles, payment terminals, and counter tops.I understand the bathroom facilities will be closed within the clinic due to guidelines.I understand that refreshments will no longer be available in the clinic.I confirm that I am not waiting for the results of a laboratory test for the coronavirus.I verify that I have not returned from any country outside of the UK in the last 14 days.I verify that I have not been identified as a contact of someone who has test positive for the coronavirus or been asked to self-isolate by The Department of Health, or any other government agency.I confirm that I am not presenting with any of the following symptoms of COVID-19 identified by the DOH: Fever > 38C, 100F Chills Body aches, Cough, Sore Throat Shortness of breath Difficulty breathing Flu-like symptoms Runny Nose Loss of smell or tasteI confirm that I am not in the high risk category for increased illness or death from COVID-19, including :diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immuno compromised (including transplant recipient),having active malignancy or over the age of 70.I understand that for the safety of everyone, my temperature will be checked before any treatment is commenced and if I refuse, I lose my appointment.I understand I may NOT bring children or anyone else who does not have an appointment into the clinic.I understand where possible I need to leave belongings away from the clinic and phones may not be taken out in the clinic.I confirm that further lock down measures or self-isolation measures taken by client or practitioner may impact any follow up appts or review appts.I understand the staff will do everything possible to minimise the spread of COVID – 19 but will not hold them responsible should I contract the COVID – 19.I will immediately notify the Clinic if I contract the virus within two weeks following my visit.I verify that the information I have provided on this form is truthful and accurate.

Submission confirmation

I understand and acknowledge that by ticking this box, I am legally agreeing to all the statements in this form.

Signature