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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.

 

 

First Client's Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
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.
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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