COVID-19 Liability Waiver

Date*

Date

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

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 GLEAUX Teeth Whitening has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that GLEAUX Teeth Whitening 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 GLEAUX Teeth Whitening and acknowledge that I am increasing my risk of 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 symptoms 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 within the last 14 days.

* I have not traveled to a highly impacted 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 GLEAUX Teeth Whitening 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 GLEAUX Teeth Whitening.

I understand that this release discharges GLEAUX Teeth Whitening 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 GLEAUX Teeth Whitening. This liability waiver and release extends to the salon together with all owners, partners, and employees.

Signature*