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COVID-19 Release form 

 

Precautionary COVID-19 Liability Release Form

 

Due to the 2019-2020 outbreak of COVID-19, we are taking additional precautionary steps mandated by the state of California in sanitation and safety practices. Please initial:


     I understand the following symptoms and affirm that I, as well as all household members, do not currently feel nor have experienced the listed symptoms within the last 14 days.

·       Fever

·       Dry Cough

·       Sore Throat

·       Chills or Shaking

·       Shortness of Breath or Difficulty Breathing


     I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days.


     I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 in the last 30 days.


    I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of the San Francisco area, that is considered a “hot spot” for COVID-19 by the Centers for Disease Control and Prevention within the last 30 days.


    I understand that it is my responsibility to refrain from touching my face throughout the appointment.


     I understand that it is my responsibility to wear a mask throughout the duration of my time in the building and to wash my hands upon arrival.

I have read the above information. If I have any concerns, I will address these with my stylist immediately. I hold Lashout SF or my lash aritst harmless from any liability for the unintentional exposure to bacteria, viruses, or other microorganisms that may cause illness or disease. I have accurately and honestly completed this form as well as the Client Intake Form. I understand my stylist will take every precaution to minimize or eliminate the spread of microorganisms within the studio. If I have additional questions or concerns throughout the appointment, I will consult my stylist immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I had sufficient opportunity for discussion and all my questions are answered. I accept the risks that may be associated with public interaction.

 

                                                                                                                  December 21, 2024

 

 

 

 

First Clients Name

First Name*

Last Name*
First Clients Age Acknowledgment*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

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

Email*

Confirm Email*
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*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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