Berkshire Hair Removal

COVID-19 Consent Form


Precautionary COVID-19 Liability Release and Consent Form

Due to the 2019-2020 Pandemic of the COVID-19, I am taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following form and sign below.

Your Name:

Email:

Have you or any household members been diagnosed with COVID-19 within the last 30 days?

Have you or any household members traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days?

Have you experienced a dry cough in the last 14 days?   

Have you experienced a loss of taste or smell in the last 14 days?

Have you experienced fatigue, tiredness or muscle pain in the last 14 days?

Have you experienced fever or chills in the last 14 days?

Have you experienced shortness of breath or difficulty breathing in the last 14 days?

Have you experienced a sore throat, body aches or pains in the last 14 days?

Have you experienced a headache in the last 14 days?

By signing below, you understand that this business, Berkshire Hair Removal, cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. Furthermore, I agree to not hold Bonnie Kelly, R.E., DBA, Berkshire Hair Removal if I do contract COVID-19 or any other contagion as I have decided to come here on my own free will.

 

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Signature Certificate
Document name: COVID-19 Consent Form
lock iconUnique Document ID: 7b76790717598ba966fb3b11576363f4f8c04573
Timestamp Audit
June 28, 2020 10:05 pm ESTCOVID-19 Consent Form Uploaded by Bonnie Kelly - bonnie@berkshirehairremoval.com IP 96.8.130.51