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:
- Difficulty Breathing
- Dry Cough
- Sore Throat
- Skin Raches
- Suddn loss of taste and smell
- Gastrointestinal upset
June 26, 2022
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.