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Precautionary Coronavirus Liability Release Form
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Name of Client:
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First Name
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Last Name
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Email Id:
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Please enter valid email address
Mobile No:
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Invalid phone number.
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Date of Birth:
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Gender:
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Female
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Due to the outbreak of the novel COVID-19, Clean Slate Spa is taking extra precautions with the intake of each client, health history review as well as sanitation and disinfecting practices.
Symptoms of COVID-19:
Fever
Fatigue
Dry Cough
Difficulty Breathing
Muscle Aches
Sore Throat
Loss of Taste & Smell
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Service Scheduled:
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I agree to the following
I understand the above symptoms and affirm that I, as well as those in my household, do not currently have, nor have experienced the symptoms above within the last 14 days
I understand the above symptoms and affirm that I, as well as those in my household, do not currently have, nor have experienced the symptoms above within the last 14 days
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I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days
I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days
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I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days
I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days
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I affirm that I, as well as those in my household, have not traveled outside of the U.S
I affirm that I, as well as those in my household, have not traveled outside of the U.S
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I understand that Clean Slate Spa and my esthetician cannot be held liable for any exposure to the COVID-19 virus
I understand that Clean Slate Spa and my esthetician cannot be held liable for any exposure to the COVID-19 virus
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I have been oriented of the following for this appointment (all must be checked):
Upon entering the building, please use the restroom to wash your hands prior to entering the suite
Upon entering the building, please use the restroom to wash your hands prior to entering the suite
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Please use hand sanitizer located outside the suite door prior to entering
Please use hand sanitizer located outside the suite door prior to entering
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A disposable mask will be provided to you. (You are more than welcome to provide your own face covering
A disposable mask will be provided to you. (You are more than welcome to provide your own face covering
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No additional persons, including family, friends, children will be allowed during your appointment. This includes waiting areas and treatment rooms
No additional persons, including family, friends, children will be allowed during your appointment. This includes waiting areas and treatment rooms
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You may be asked to remain in your vehicle instead of congregating in the waiting area prior to your appointment
You may be asked to remain in your vehicle instead of congregating in the waiting area prior to your appointment
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By signing below, I agree to each of the above statements and release Clean Slate Spa and its owner from any and all liability for the unintentional exposure of or harm from COVID-19.
Clean Slate Spa agrees they will also abide by these same standards and affirm the same.
Clean Slate Spa also affirms the continuous improvement and expanded santitation protocols to fight the spread of COVID-19 and other communicable diseases.
Signature of Clean Slate Spa Client:
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Date Signed:
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
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