COVID-19 Prescreening form, information and Consent Form

Pure Skin Makeup & Skincare Studio

COVID-19 Pre-screening Form, Information & Liability Waiver
Please complete within 24 Hrs of your appointment only.

(not the morning of your appointment or two days before, I need the form to be as accurate as possible within 24hrs of your scheduled appointment, thank you)
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *

Area Code Phone Number
Email
example@example.com
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 preventative measures have been put in place to further reduced the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions: *

YES

Do you have a fever or above normal temperature?

Have you experienced shortness of breathe or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19?

Have you tested for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship in the past 14 days?

Have you traveled within the United States, by air, bus or train within the past 14 days?

Do you have a weakened immune system?

Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?

Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your physician or our office if not sure. Also, answer YES if unsure.

Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?

Do you have diabetes?

If so, do you have to take insulin injections?

Do you have asthma or COPD?

To the best of your knowledge have you been in close proximity to any individual who tested positive for Covid-19?

Have you attended any large social gatherings within the last 14 days?

Explain any YES answers in the box below:
Signature: By typing your name in the box below, you acknowledge that answers you provided are true and accurate to the best of your knowledge: *

Clear
Consent for Treatment

I understand that, becuase esthetics involves maintained touch and close physical proximity over and extended period of time, there may be an elevated risk of disease transmission, incuding COVID-19. By signing this form, I acknowledge that I am aware of the risk involved from receiveing treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims relted thereto. I give my consent to receive treatment from this practitioner.
By checking this box I understand and consent to services/treatment

Check and sign below
Client Signature

Clear
Parent or Guardian Signature (in case of a minor):

Clear
Studio Guidelines
- All clients must wear a face mask to their scheduled appointment.
- Shoes off upon entry.
- Do not wear gloves into studio, upon entry, you must immediately wash and sanitize hands. (no exceptions)
- Please come alone. No one other than the client receiving services will be allowed into the studio, unless it’s a minor in which case, parent must also follow social distancing, wear a mask and follow all guidelines outlined.
- Please remain in your vehicle and text me when you have arrived. Once I am ready for you I will text you back to enter the studio.
- Please understand that your appointment may run a few minutes behind or be a little longer than usual. I am taking all precautions and incorporating even longer disinfecting protocols between each client and this may require extra time, therefore be patient.
- Do not bring any food, drinks or any extra item beyond what is absolutely necessary into the studio. (upon entry, there will be a plastic bin you may put any belongings)
- Do NOT come to the Studio if you or anyone you live with have been exposed to is self-isolating or displaying symptoms known to be consistent with Covid-19
by checking this box I understand and accept the above guidelines and will follow them.
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Pure Skin Makeup & Skincare Studio

Please complete within 24 Hrs of your appointment only.