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 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 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 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.