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COVID-19 Information & Liability Waiver

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures Luna Beauty and Wellness has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

Consent for Treatment

I understand that, because personal services offered at Luna Beauty and Wellness involve close physical proximity and/or maintained touch over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless Luna Beauty and Wellness and the practitioner from any claims related thereto. I give my consent to receive treatment from this business and practitioner.

Today's date: September 17, 2021

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
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

COVID-19 Information

Have you had a fever in the last 24 hours of 100°F or above?*
No
Yes
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
No
Yes
Have you recently experienced ANY symptoms of ANY illness?*
No
Yes
In the last 14 days have you had contact with anyone who has tested positive for COVID-19 or has experienced any symptoms of any illness?*
No
Yes
Are you vaccinated?*
No
Yes
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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