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COVID-19 Screening Form

 

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 unfavorable outcome, for which your service provider will not held liable.

The inofrmation provided is done so in confindence and will not be shared with outside parties. 

 

Due to the 2019-2020 outbreak of the novel corona virus COVID-19, we are taking extra precautions with the intake of each client, obtaining a health history review, increasing sanitation and disenfecting practices, and wearing of protective gear by service providers and clients alike. 

Please complete the following below.

 

Symptoms of COVID-19 include:

  • Fever
  • Chills/Shakes
  • Difficulty Breathing
  • Dry Cough
  • Sore Throat
  • Sneezing 
  • Skin Raches
  • Suddn loss of taste and smell
  • Gastrointestinal upset

 

May 18, 2021

 

Coronavirus / Flu Screening Questions:

 

I Agree
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 bove within the last 21 days.

I Agree
I affirm that I, as well as all househols members, have NOT been diagnosed with COVID-19 within the last 30 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 30 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 not beem cosidered a "hot spot" for COVID-19 infections within the last 30 days. 

I Agree
I understand that clinic screens all clients and team members for possible COVID-19 infections per the current guidelines. However, carriers of the virus may be completely asymptomatic as the COVID-19 visrua 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 thia clinic strictly adheres to the CDC, Federal and Provincial Health Authority standards as they currently exist, COVID-19 is the new highly contagious pathoghen that xcan be transmitted to an from the clinic, service providers even under strict followed standards. This virus can be spread through droplets or contact.*

I Agree
I understand that due to other clients visiting the clinic for treatments or due to the characteristics of the virus , I have an elevated risk of contracting the virus simply by being by the building.*

I Agree
I understand Provincial Health Authority recommend a physical distancing of at least 6 feet, and this is not possible when seeking beauty treatments provided within this location.*

I Agree
I understand that this business E SKIN FORTE and my Esthetician Emilie Duke cannot be held liable for any exposure to the virus or any other conatgion caused by misinformation on this form or the health history provided by each client.

 

CONSENT:

By signing below, I agree to each above statement and release my Esthetician Emilie Duke and her business E SKIN FORTE  from any and all liablity for the unintentional exposure or harm due to COVID-19.

Your Esthetician and team members of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

 

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's 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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

Middle Name

Last Name*

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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