Covid-19 Liability Release Form

General Information

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

The following services are requested today:

Has anything changed since your last appointment regarding your health, medications, allergies, sensitivities, skin conditions, or recent procedures that may affect today's service?

Are you currently experiencing any irritation, infection, open/broken skin, swelling, or other concern in the area being treated?

I agree to the following:
I confirm the information above is accurate and I have disclosed anything that may affect today's service. I understand that reactions and results vary, and I consent to the service(s) being performed today.

By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.

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Signature

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Intake Form