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COVID-19 Precautionary

Release Form

 

Here at Meghan Barbour - brow+beauty I take pride in providing you with the safest and most sanitary service(s) possible.

Due to the COVID-19 outbreak I am taking extra precautions with each and every client. These precautionary measures are to protect you, your loved ones, other clients and myself. One of the measures that I am taking is to have each client fill out this brief questionnaire before beginning their service(s). Each client will also have their temperature checked (when available).

COVID-19 symptoms include but are not limited to: fever, chills, headaches, nausea, runny nose (without reason), dry cough, breathing difficulty, shortness of breath, fatigue, possible loss of smell, and sore throat.

Date: October 29, 2020

First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

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*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I have read the above symptoms and can confirm that I nor anyone in my household or social bubble has had any of the above symptoms within the past 14 days*
No
Yes
I can confrim that I have not traveled outside of Canada or to any areas which are deemed "hot spots" within in the last 30 days*
No
Yes
I can confirm that myself as well as other members of my household or social bubble have not knowingly been exposed to or diagnosed with COVID-19 within the past 21 days*
No
Yes
I can confirm that I will in no way hold liable any and all of the following: Meghan Barbour, owners or any related entities in the event that I may become ill with COVID-19*
No
Yes

By signing this form, I have read and understand all of the above statements. I have answered each one truthfully and honestly. I understand that if I have any symptoms of COVID-19 or have answered no to any of the above questions that services can not be provided. I also understand that this form will be kept on file for contact tracing purposes.

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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