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Due to the 2019-2020 Pandemic of the Novel Coronavirus (COVID-19), We are taking extra precautions to ensure the safety and well-being of my clients and myself; as well as continuing to follow strict sanitation practices put in place by governing State Board of Regulation and/or State Department of Health, as well as CDC Guidelines.

I attest that as of this date, I have not experienced any of the following symptoms within the last 14 days:

Fever or chills


Cough


Shortness of breath or difficulty breathing


Fatigue


Muscle or body aches



Headache



New loss of taste or smell



Sore throat



Congestion or runny nose


 Nausea or vomiting


 Diarrhea


Please read and check each box to agree to the statement:

I understand the above symptoms and affirm that I, as well as all household members and co-workers, do not currently have, nor have experienced any symptoms listed above within the last 14 days.

I Agree
 

I, as well as household members and co-workers, have not been diagnosed with COVID-19 in the last 60 days.

I Agree

I, as well as household members and co-workers, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 60 days.

I Agree

I, as well as household members and co-workers, have not traveled outside of the country, or to any city outside of their own that is or has been considered a “hot spot” for COVID-19 infections in the last 30 days.

I Agree

I understand that Natrabella Skincare LLC  and its staff of course 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

By signing below, I agree to each above statement and release Natrabella Skincare LLC from any and all liability for the unintentional exposure due to COVID-19. All our employees agree and abide by these same standards and attest the same.

 

 

Fill out the waiver by scanning Your Driver's License

This scanner is designed as an optional onsite tool to streamline the waiver-signing process. If you are not at the business' location or prefer not to scan your license please skip this option and proceed below to fill out the waiver.

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First Client's Name
First Name*
Middle Name
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Signature*
Second Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Third Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Fourth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Fifth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Sixth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Seventh Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Eighth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Ninth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Tenth Client's Name
First Name*
Middle Name
Last Name*
Client's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email
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Email me a copy of this document.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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*
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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