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:
- 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