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Lux Tan / Lux Cryo Covid-19

 

COVID-19 RELEASE WAIVER


Due to the 2019-2020 outbreak of the novel coronavirus, COVID-19, we are taking extra precautions with the intake of each client, obtaining a healthy history review, increasing sanitation and disinfecting practices and wearing of protective gear by service providers and clients alike. Please complete the following and sign below.
Please be honest when filling out this form. If you do not fully disclose the information asked, any services provided based on the information you give could result in an unfavorable outcome, for which your service provider will not be held liable. The information provided is done so in confidence and will not be shared with outside parties.


Symptoms of COVID-19 include:
• Fever
• Chills/Shakes
• Difficulty Breathing
• Dry Cough
• Sore Throat
• Sneezing
• Skin Rashes
• Gastrointestinal Upset 

Coronavirus Screening Questions
Please read and initial next to each statement.  If you cannot truthfully affirm every statement in this document by affixing your initials, today’s service(s) will be refused, you will need to reschedule your appointment for a later date, and this appointment will be subject to your service provider’s late cancellation policy.
  
I understand the above symptoms and affirm that I, as well as my household members, DO NOT currently have, nor have we experienced the symptoms listed above within the last 21 days.

I Agree

I affirm that I, as well as all household members, have NOT been diagnosed with COVID-19 within the last 21 days.

I Agree


I affirm that I, as well as all household members, have NOT knowingly been exposed to anyone diagnosed with COVID-19 within the last 21 days.

I Agree


I affirm that I, as well as all household members, have NOT traveled outside of the country, or to any city outside of our own that has been considered a "hot spot" for COVID-19 infections within the last 21days.

I Agree


I understand that this location screens all clients and service providers for possible COVID-19 infections per the current guidelines. However, carriers of the virus may be completely asymptomatic as the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and can still be contagious. Some may never develop severe symptoms. While this location strictly adheres to the CDC standards as they currently exist, COVID-19 is a new highly contagious pathogen that can be transmitted to and from the service providers even under strictly followed standards. This virus can be spread through droplets or contact.

I Agree


I understand that due to other clients visiting this location for services and due to the characteristics of the virus, I have an elevated risk of contracting the virus simply by being in the building or any other public facility.

I Agree


I understand the state of Oregon and Washington recommends physical distancing of at least 6 feet, and this is not always possible when seeking services provided within this location.

I Agree


I understand that this business and service provider cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

I Agree



Consent:
By signing below, I agree to each of the above statements and release my service provider and Lux Tan LLC and or it's assigns from any and all liability for the unintentional exposure or harm due to COVID-19.
Your service provider and all team members of this facility also affirm that they have improved and expanded the sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.


Client Signature:
   Date: August 7, 2020
 

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Second Clients Signature*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Third Clients Signature*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Signature*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Signature*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Signature*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Signature*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Signature*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Signature*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Signature*
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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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