Precautionary COVID-19 Intake form
Due to the 2019-2020 Pandemic of the Novel Coronavirus (COVID-19) we are taking Extra Precautions. Each client will be required to fill out a health history review form. Please complete the following form honestly for the safety of your Esthetician or Massage Therapist, and all of our clients.
Common Symptoms of COIVD-19 May Include (But not limited to):
-Dry Cough - Sore Throat
-Fatigue/Tiredness - Body Aches/Pain
-Fever - Headache
-Shortness of Breath - Rashes on skin
Please Read each line carfully:
*I Affirm that I, as well as all people in my household, do not currently have COVID-19, nor have tested positive with COVID-19 within the last 30 days
* I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced any of the symptoms listed above within the last 14 days
* I Affirm that, I as well as all members of my household, have not traveled outside of the country, or to any state or city that is considered a “hot spot” for COVID-19 infections within the last 30 days.
* I understand that, because esthetics and massage involves maintained touch and close physical physical proximity over and extended period of time, there may be an elevated risk of disease transmission, including COVID-19.
By Signing this form, 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 the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
Your technician and Renewed Skin and Body, also agree that they abide by these same standards and affirm the same. We also affirm that we have expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable disease. We are following the cleaning procedures that the CDC recommends. A list of our cleaning procedures are available upon request.