COVID-19

1

COVID-19 Questionnaire

First Name

Last Name

2

Date

3

Have you had a fever in the past 7 days?

YESNO

4

Do you now, or recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?

YESNO

5

Have you traveled outside of the country in the past 14 days?

YESNO

6

Have you been in contact in the past 14 days with anyone who has been diagnosed with COVID 19 or has had Coronavirus type symptoms?

YESNO

7

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventitive measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

8

CONSENTMENT OF TREATMENT

I understand that, because esthetics involves maintained touch and close physical proximity over an extended amount of time, there may be an elevated risk of disease transmission, including COVID19. By signing this form, I acknowledge that I am aware of the risks involved from receiving this treatment at this time. I voluntarily agree to assure 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.

9

Signature

Clear