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 Attestation & Protocol Acknowledgement Form

{SARS-CoV2}
Guest Name*

First NameLast Name
If under 18, parent/guardian must sign agreeing to attest & authorize all statements above on behalf of their child.
Today's Date*

MonthDayYear
Date
Company Email:
example@example.com
Attestation Details

I, the undersigned, do hereby attest that, to the best of my knowledge, I have not come in contact with any person(s) that tested positive for COVID-19, the disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), in the previous three (3) weeks, nor have I tested positive for the COVID-19 disease or displayed any of the below listed symptoms in the previous three (2) weeks.

I authorize Rubiology Electrology to release my information for contact tracing purposes if requested by a local, state or federal official. This information includes but not limited to legal name, address, telephone number(s), dates of electrolysis treatments and copies of signed COVID-19 attestation forms. Should my information be released, Rubiology Electrology is obligated to notify me and provide copies of all information released. All non-COVID-related personal information will remain private per guidelines of the Health Insurance Portability and Accountabilty Act (HIPPA).

I agree to comply with Rubiology Electrology' mandated safety protocols when visiting the Rubiology Electrology office located at 237 W. 4th Street, Claremont, California 91711. I also understand that Rubiology Electrology has the right to refuse service if I am unwilling to comply with the mandated safety protocols OR if I have engaged in activities that are deemed high risk in the previous three (3) weeks. The definiton of “high-risk” will remain at the discretion of the Rubiology Electrology electrologist.

I release Rubiology Electrology of any legal, civil, or criminal liabilities should I contract any strain of COVID-19 on or after the dates listed below, and I understand a re-attestation will be required at each treatment session in order to provide Rubiology Electrology with the most up to date information in efforts to keep all clients and electrologists safe.
Symptom Check
Do you have any COVID-19 symptoms? According to the Centers for Disease Control and Prevention website, please list if you have any below symptoms.

CoughShortness of Breath or Difficulty BreathingFeverChillsMuscle PainSore ThroatNew Loss of SmellNew Loss of TasteRed, Pink or Blue Lesions on ToesUnusual Blisters or RashSwollen Lips, Mouth, Hands or Feet
Client Acknowledgement of Information
Have you ever been tested for COVID-19?     *

If yes, when?   Date   What were the results?

Have you or any member of your household had COVID-19?

Dates they had illness?   To:Date  From   Date

Additional information:
By signing below, you are declaring the foregoing is true, that you agree to take all recommended and reasonable actions to protect yourself and others from exposure to COVID-19, and that you assume the risk of entering the Rubiology Electrolysis facility. You understand and agree that no one, including but not limited to the Electrolysis, can guarantee that you will not be exposed to or contract COVID-19.
I agree to the terms as stated above and attest that all information provided is true and accurate.
Guest Signature:

Clear
Date of Guest Signature:*

MonthDayYear
Date
Patent's Name (If minor)

First NameLast Name
THANK YOU FOR YOUR BUSINESS

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

COVID-19 Attestation & Protocol Acknowledgement Form

Symptom Check

Client Acknowledgement of Information

THANK YOU FOR YOUR BUSINESS