Covid-19 PMU Services Consent Form

Name

First NameLast Name

Date

PLEASE STAY HOME IF YOU ARE SICK

Social distancing will be strictly enforced. Only the person being serviced is allowed to enter the studio.

Once you have parked your car, please text (706)-828-1795. Entry will be allowed at exact appointment time.

I understand that the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious.

I understand that physical distancing of 6 feet may not be possible while receiving services.

I understand that I must sanitize my hands before entering the salon and I must wear a mask that covers my mouth and nose. Hard surfaces such as door handles, Ipads, payment terminals, and countertops will be wiped after each client.

I confirm that I am not currently positive for novel coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not returned to Georgia from any country outside of the US, whether by car, air, bus or train in the past 14 days.

I verify that I have not been identified as a contact of someone who has test positive for the novel coronavirus or been asked to self-isolate by The Georgia Department of Health, or any other government agency.

I confirm that I am not presenting with any of the following symptoms of COVID-19 indentified by the CDC
            Fever > 38C, or 100F, chills or body aches
            Cough
            Sore Throat
            Shortness of breath
            Difficulty breathing
            Flu-like symptoms
            Runny Nose
            Loss of smell or taste

I confirm that I am not in high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy or over the age of 65.

I understand that for the safety of everyone, my temperature will be check before the services are started.

I understand that I may be unable to proceed with services if they are deemed unsafe to myself or a staff member

I understand I may NOT bring children or anyone else who does not have an appointment.

I understand the will do everything possible to minimize the spread of COVID – 19, but will not hold them responsible should I contract the COVID – 19.

I will immediately notify the Misty Williams 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.

Signature

Consent for services during Covid-19 Pandemic