Name

First Name

Last Name

Date of Birth

YYYY

Due to the 2019-2020 pandemic of the Novel Cornavirus (COVID-19). We are taking EXTRA precautions with the intake of each clients, health history review as well as sanitation and disinfecting practices. Please kindly complete the following and sign below:

Common Symptoms of COVID-19 may include (but not limited to):

• Dry Cough • Fatigue or Tiredness • Fever • Shortness of Breath • Sore Throat • Body Aches/Pains • Headache

I agree to the following:

I affirm that I, as well as all household members have not been diagnosed with COVID-19 within the last 30 days

I understand that the above symptoms and confirm that I, as well as all household members do not currently have, nor have experienced any symptoms listed above within the last 14 days

I affirm that, I as well as all household members, have not traveled outside of the country or to a city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days

I understand that this business and my Aesthetician/Nurse cannot be held liable for any exposure to the virus or any other contagion cause by misinformation on this form or the health history provided by each client

I agree to not hold Skin Oasis or it’s associates if I contract COVID-19 or any other contagion as I have decided to come here on my own free will.

BY signing below, I agree to each above statement and release Skin Oasis from any and all liability for the unintentional exposure or harm due to COVID-19

Your Aesthetician/Nurse and all Employees of this facility agree that they abide by these same standards and affirm the same. We also can confirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Signature

Date

YYYY