COVID-19 Attestation Form

Rubiology
237 W. 4th St.
Claremont, CA 91711
Call or Text: 909-624-8617
https://www.therubiology.com/
rubiologyelectrology@gmail.com
IG rubiology__
COVID-19 Safety Attestation and Protocol Agreement
Guest Name*

First NameLast Name
Are you above the age of 18?*

Yes, I am over the age of 18No, I am a Minor
If the guest is a minor, the following section must be completed by a parent or legal guardian:
Parent/Guardian Name:*

First NameLast Name
Relationship to Minor:*
Company Email:
example@example.com
Parent/Guardian Acknowledgment (For Minors Only)
I, {parentguardianName}, certify that I am the parent or legal guardian of {guestName}, the minor named above. By signing this form, I attest that I understand and agree to all terms and conditions outlined in this COVID-19 Attestation & Protocol Acknowledgement Form on behalf of the minor. This includes accepting responsibility for any fees incurred as a result of cancellations or rescheduling in accordance with Rubiology Electrology’s cancellation policy.

I further acknowledge and accept the risks associated with COVID-19 and its variants, and I release Rubiology Electrology from any legal liability should the minor contract COVID-19 or its variants.
Attestation Details
I, {guestName}, attest that to the best of my knowledge:
- I have not tested positive for COVID-19, including any known variants, in the past 10 days.
- I have not experienced any of the following symptoms associated with COVID-19 in the past 10 days:
  - Cough
  - Shortness of Breath or Difficulty Breathing
  - Fever
  - Chills
  - Muscle Pain
  - Sore Throat
  - New Loss of Smell
  - New Loss of Taste
  - Red, Pink, or Blue Lesions on Toes
  - Unusual Blisters or Rash
  - Swollen Lips, Mouth, Hands, or Feet
- I have not been in close contact with anyone confirmed to have COVID-19 in the past 10 days.
Consent for Information Release
I, {guestName}, authorize Rubiology Electrology to release my information for contact tracing purposes if requested by local, state, or federal health officials. This information may include my legal name, address, telephone number(s), dates of electrolysis treatments, and copies of signed COVID-19 attestation forms. Rubiology Electrology will notify me and provide copies of all information released. All non-COVID-related personal information will remain confidential in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Agreement to Comply with Safety Protocols
I, {guestName}, agree to adhere to Rubiology Electrology's mandated safety protocols when visiting the office at 237 W. 4th Street, Claremont, California 91711. I understand that Rubiology Electrology reserves the right to refuse service if I do not comply with these protocols or if I have engaged in activities deemed high risk in the past 10 days. The definition of "high-risk" activities is at the discretion of the Rubiology Electrology electrologist.

Assumption of Risk
I, {guestName}, acknowledge that while Rubiology Electrology follows all applicable health guidelines, there is a potential risk of exposure to COVID-19. I assume this risk and release Rubiology Electrology from any legal liability should I contract COVID-19 or any of its variants. I understand that a new attestation will be required at each treatment session to provide the most up-to-date information to keep all clients and staff safe.
Client Health Screening Questions
1. Are you currently experiencing any symptoms associated with COVID-19, as listed above?*

YesNo
If Yes, please list symptoms:*
2. Have you been tested for COVID-19 in the past 10 days?*

YesNo
If Yes, what were the results?*
3. Have you or any household members tested positive for COVID-19 in the past 10 days?*

YesNo
If Yes, please provide the dates of illness:*
Declaration and Agreement
By signing below, I, {guestName}, declare that the information provided is true and accurate. I acknowledge and accept that, while Rubiology Electrology adheres to applicable health guidelines, there remains a risk of exposure to COVID-19 and its variants. I assume this risk and release Rubiology Electrology from any legal liability should I contract COVID-19 or any of its variants.

I also understand that Rubiology Electrology's cancellation policy applies to all appointments, including those cancelled or rescheduled due to COVID-19 or its variants.

I agree to provide notice in accordance with the cancellation policy to avoid any associated fees.

I, {guestName}, agree to the terms as stated above and attest that all information provided is true and accurate.
Guest Signature:*

Clear
Parent/Guardian Signature: *

Clear
Date of Signature:*

MonthDayYear
Date
THANK YOU FOR YOUR BUSINESS

Rubiology
Electrologist Notes & Observations For office use only
Should be Empty:

COVID-19 Safety Attestation and Protocol Agreement

Client Health Screening Questions

Declaration and Agreement

THANK YOU FOR YOUR BUSINESS