Facial Consent for COVID-19

Name

First NameLast Name

Birth Date

MonthDayYear

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

A weak immune system can put you at greater risk for contracting COVID-19. Please select the ones that apply.

Please disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Have you tested positive for COVID-19?

YesNo

Have you been tested for COVID-19 and are awaiting results?

YesNo

Have you been in contact with someone who has tested positive for COVID-19?

YesNo

Have you traveled abroad by air or cruise ship in the past 14 days?

YesNo

Please select the signs or symptoms that you are currently experiencing or have experienced within the last 14 days.

Further Comments

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Orange County Microcurrent has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Orange County Microcurrent can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.

I voluntarily seek services provided by Orange County Microcurrent and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that:

* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

* I have not traveled internationally or to a high risk area within the last 14 days.

* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.

* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Orange County Microcurrent harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Orange County Microcurrent. I understand that this release discharges Orange County Microcurrent 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 Orange County Microcurrent. This liability waiver and release extends to the salon together with all owners, partners, and employees. I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Date

Signature

COVID-19 Treatment Consent