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[​COVID-19] PRE-APPOINTMENT

HEALTH SCREENING 

QUESTIONNAIRE

 

 

July 29, 2021

PRIOR TO THE START OF MY SERVICE, I CONFIRM THAT:

Within the past 14 days, I have NOT been diagnosed with or cared for someone diagnosed with COVID-19 

I Agree

Within the past 14 days, I have NOT shown symptoms of COVID-19 or come in close contact with anyone exhibiting symptoms.

I Agree

Within the next 14 days, should I begin to show symptoms of COVID-19, I will notify Hush Tan.

I Agree

Within the past 14 days, i have not traveled by plane. 

I Agree

WHILE INSIDE HUSH TAN I AGREE TO:

Wear a mask, keeping it placed above my nose and below my chin, UNLESS instructed otherwise by my service provider.

I Agree

Maintain SIX (6) feet distance from everyone with the exception of my service provider. 

I Agree

Follow all posted and verbal instruction to keep myself and those around me safe.

I Agree

IF YOU ARE UNABLE TO AGREE TO ANY OF THESE ITEMS PLEASE CONTACT US AT (503)341-4013 IMMEDIATELY TO RESCHEDULE.

COVID-19 WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

In consideration for receiving services from Hush Tan, I hereby acknowledge and agree to the following:

I understand the hazards of the novel coronavirus (“COVID-19”) and am familiar with the Centers for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19. I acknowledge and understand that that the circumstances regarding COVID-19 are changing from day to day and that, accordingly, the CDC guidelines are regularly modified and updated and I accept full responsibility for familiarizing myself with the most recent updates.

Notwithstanding the risks associated with COVID-19, which I readily acknowledge, I hereby willingly choose to receive services.

I acknowledge and fully assume the risk of illness or death related to COVID-19 arising from my being on the premises and engaging in services hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE (on behalf of myself) HUSH TAN, their owner, officers, directors, agents and employees (the “RELEASEES”) from any liability related to COVID-19 which might occur as a result my being on the premises and engaging in services.

I shall indemnify, defend and hold harmless the RELEASEES from and against any and all claims, demands, suits, judgments, losses or expenses of any nature whatsoever (including, without limitation, attorneys’ fees, costs and disbursements, whether of in-house or outside counsel and whether or not an action is brought, on appeal or otherwise), arising from or out of, or relating to, directly or indirectly, the infection of COVID-19.

It is my express intent that this Waiver and Hold Harmless Agreement shall bind any assigns and representatives, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above-named RELEASEES. This Agreement and the provisions contained herein shall be construed, interpreted and controlled according to the laws of the State of Oregon.

IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Agreement for full, adequate and complete consideration fully intending to be bound by 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*
Client's 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*
Check to receive information, news, and discounts by e-mail.
CLIENT HEALTH CHECKLIST:
Have you had a COUGH? (within the past 14 days)*
No
Yes
Have you had a FEVER? (within the past 14 days)*
No
Yes
Have you experienced increased FATIGUE? (within the past 14 days)*
No
Yes
Have you experienced SHORTNESS OF BREATH? (within the past 14 days)*
No
Yes
Have you experienced LOSS OF TASTE OR SMELL? (within the past 14 days)*
No
Yes
Have you experienced ANY of the following: CHILLS, REPEATED SHAKING, HEADACHE, MUSCLE ACHES or PAINS, SORE THROAT, RUNNY or STUFFY NOSE, NAUSEA OR DIARRHEA? (Within the past 14 days)*
No
Yes
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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