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This is a COVID-19 liability realease waiver. Please read through carefully to ensure proper understanding of The Primping Place's procedures. Please note : if you have recently been on an airplane or traveled outside of CT there is a mandatory 14 day quarantine that you must complete prior to your appointment. Also if you have been in a group of 10 or more indoors we need to wait 2 weeks from that exposure to see you.

If you have been exposed and told to quarantine around the time of this appointment please let us know immediatley so we can take appropriate measures to protect ourselves & other clients. Thank you for understanding. 

By signing below, I understand that The Primping Place Spa, The Primping Place,  Electrolysis and Skincare by Lisa A. Primps LLC and Lisa Primps formally known as Lisa Mecca cannot be held liable for any exposure to the Covid-19 virus caused by mis-information on this form or the health history provided by each client. 

By signing below I agree to each statement above and release The Primping Place Spa, Electrolysis and Skin Care by Lisa Primps doing business as The Primping Place, and Lisa Primps formally known as Lisa Mecca from any liability and from the unintentional exposure or harm to COVID-19. 

It is my understanding that The Primping Place is following recommended guidelines from the centers for disease control and that having any service performed without the ability to socially distance does involve a level of risk. I release The Primping Place, Lisa Primps, Lisa Mecca,  Electrolysis and Skincare, and Lisa Mecca-Primps from any and all liability. 

Should I find after this appointment that I may have been exposed I will contact The Primping Place to ensure they take appropriate steps to quarantine. 

February 28, 2021

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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 Information
Have you experienced recent loss of taste or smell?*
No
Yes
Have you had any contact with any confirmed COVID-19 positive patients?*
No
Yes
Is your age over 60?*
No
Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
No
Yes
Have you traveled in the past 14 days on an airplane or to any regions affected by COVID-19?*
No
Yes
Current restricted states as of 7/29/2020:
Alaska Alabama Arkansas Arizona California Delaware Florida Georgia Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Mississippi Montana North Carolina North Dakota Nebraska New Mexico Nevada Ohio Oklahoma Puerto Rico South Carolina Tennessee Texas Utah Virginia Washington Washington DC Wisconsin And any air travel at all.

Today's date

have you had fever or been sick within the past 14 days? *
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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