COVID-19 Liability Release Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
(The Client) Consent to the procedure of
Are you, or any of your household members, experiencing any of the following symptoms?
Fever
Cough
Chills
Fatigue
Muscle Pain
Sore throat
New loss of taste or smell
I understand the above symptoms and affirm that I and any household members, do not currently have nor experiencing the above symptoms within 14 days.
I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
Initial
I understand that based on what is known about COVID-19, the spreads through to occur mostly from to person via respiratory droplets amount close contact. This spreads can be 6 ft. More or less.
Initial
I confirm that I do not display or currently have any of the symptoms that are listed above.
Initial
My Technician/ Service provider is not liable for my exposure to COVID-19 or any other viral disease or disorders.
Initial
Have you travelled outside of B.C or have had close contact with anyone who has travelled in past 14 days?
Yes
No
Have you travelled off Vancouver Island or have had close contact with anyone who has travelled in past 14 days?
Yes
No
Have you had close contact with anyone with respiratory illness, confirmed or probably/suspected case of COVID-19?
Yes
No
In Signing this agreement, I acknowledge and represent that I have read this entire waiver of liability and hold harmless agreement. I agree with it, understand and have voluntarily signed each statement. We have the right to refuse service to our discretion.
Clear
Date
-
Month
-
Day
Year
Date
Submit
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