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Permanent Beauty by Ieva
Ieva Oliveira
Browsbyieva@gmail.com
416.804.6749

Precautionary COVID-19 Release Form

Please read and initial all line

Ideal Skin will be taking precautions with each client such as temperature and health history. We will also be implementing additional protective, sanitization and disinfecting practices before, during and after each client. Please read and complete the following.

Symptoms of COVID -19 include and are not limited to:

  • Fever
  • Fatigue
  • Difficulty breathing
  • Dry cough

I agree to have my temperature taken and to reschedule my appointment should my temperature exceed the normal range of 96.8- 99 degrees Fahrenheit.

I understand and affirm I and all members of my household are free from the above symptoms and have been in the last 14 days.

I affirm myself nor any members of my household have not been diagnosed with COVID-19 in the last 30 days.

I affirm myself nor any members of my household have not been knowingly exposed to anyone diagnosed with COVID-19 in the last 30 days.

I affirm myself nor any members of my household have not been out of the country or traveled to any known COVID-19 “hot spot” states in the last 30 days.

I agree to wear a protective mask for the duration of my visit.

Should my elective procedure include the nose or mouth area I agree to keep my mouth closed for this portion of the treatment. The practitioner will wear both a mask and full facial shield for the entirety of the procedure.

I understand that Ideal Skin, nor my practitioner are not liable for any exposure to the virus or any other contagion during my visit.

I affirm my procedure is elective and in no way medically necessary, I chose to be here on my own accord.

My signature below indicates I agree to each of the above statements and release my practitioner and the business from any and all liability for the unintentional exposure to the COVID-19 virus.

All practitioners of this facility agree to abide the same standards and affirmations. We also affirm we have improved and expanded our sanitation protocols to thoroughly to prevent the spread of COVID-19 and other communicable conditions.

Today's Date: November 25, 2020

Please select who will be participating...
AdultMinor
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First Client Name

First Name*

Last Name*
First Client Date of Birth*
First Client Information

Current Temperature (AM/PM):
First Client Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Current Temperature (AM/PM):
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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