Covid-19 Liability Waiver

Covid-19 Liability Waiver

By submitting this form you agree to have esthetic services during the pandemic with Kroh Beauty. Debbie Kroh is strictly following all the Santa Clara and CDC guidelines, and have invested in every way possible to keep my clients and myself safe during this time.
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Client Name

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By checking the boxes, you confirm that you agree with the following statements:

I acknowledge that Debbie Kroh can not guarantee that I will not become infected with COVID-19.I agree to obey the rules of Kroh Beauty during my appointment in order to minimize the spread of COVID-19.I confirm that I have NOT been diagnosed with COVID-19 last 14 days.I verify that I am NOT waiting for the laboratory test results for COVID-19.I understand that this release discharges Debbie Kroh from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Debbie Kroh. This liability waiver and release extends to the salon together with all owners, partners, and employees.
Are you fully vaccinated?

YesNoJust 1st vaccineJust got 2nd, but hasn't been 2 weeks
Have you gotten your Booster?

YesNo
Have you traveled in the past 2 weeks?

YesNo
Do you have kids or family members that are NOT VACCINATED?

YesNo
Do you have any of these symptoms - cough, shortness of breath or difficulty breathing, high fever, muscle pain, body ache, nausea, loss of taste/smell, sore throat, repeated shaking with chills?

YesNo
I am following all CDC guidelines as much as possible and limiting my exposure to COVID-19.

YesNo
Have you been diagnosed or suspected of having COVID-19?

YesNo
Within 30 days, have you been in contact with anyone that has COVID-19 symptoms or been infected?

YesNo
Are you living with anyone that is infected or quarantined due to COVID-19?

YesNo
Have you or your family members or close contacts recently travelled in the U.S or internationally within the past 30 days?

YesNo
I agree not to visit Kroh Beauty for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

I understand that because esthetics involves maintained touch and close physical proximity over an 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 during this time. I voluntarily agree to assume those risks and I release and hold harmless Debbie Kroh from any claims related thereto. I give my consent to receive treatment from Debbie Kroh.

If you have been sick in the past 72 hours or are feeling unwell please reschedule your appointment at no charge.
Parent/Guardian Name (if applicable)

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Client/Parent/Guardian Signature

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