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Covid-19 Liability Waiver


Review Privacy Policy

     I understand that I am opting for an elective service which bears inherent risk.

     I also understand that COVID-19 has been declared a worldwide pandemic by the World Health Organization.  I further understand that COVID-19 is extremely contagious and is believed to spread by person to person contact; and as a result, federal and state health agencies recommend social distancing. 

     I recognize that la mar salon has been monitoring the situation, and has put in place reasonable preventative measures aimed to reduce the spread of COVID-19.  By virtue of proceeding with this elective service, I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective service, and give my express permission for la mar salon to proceed with my service. 

     I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test.  I understand that possible exposure to COVID-19 before/ during/ after my service, may result in the following;  a positive COVID-19 diagnosis, extended quarantine/ self isolation, additional tests, hospitalization that may require medical therapy, Intensive care treatment, possible need for intubation/ ventilator support, short term or long term intubation, other potential complications, and the risk of death.  

     I have been given the option to defer my service to a later date.  However, I understand all the potential short term and long term risks related to COVID-19 , and would like to proceed with my desired service. 

                            

 

INFORMED CONSENT FOR COVID-19 RISK,  I UNDERSTAND THE EXPLANATION, AND HAVE NO MORE QUESTIONS AND CONSENT

 

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Clients Date of Birth*
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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*

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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