COVID-19 LIABILITY RELEASE WAIVER

COVID-19 Liability Release Waiver
Signature Required Prior to Every Scheduled Appointment

Due to the 2020 outbreak of the novel Coronavirus, (COVID -19), Clear Solutions Acne & Skin Care Clinic is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the New York States guidelines.

Please complete the following and date and sign

Symptoms of COVID-19 can include:
• Fever
• Fatigue
• Dry cough
• Difficulty breathing
• Skin Rashes
• Sneezing
I understand the above symptoms and affirm that I, as well as any of my household members, DO NOT currently have, nor experienced the symptoms listed above within the last 21 days.*
- Yes
- No
I affirm that I, as well as any of my household members, have NOT been diagnosed with COVID-19 within the last 30 days.*
- Yes
- No
I affirm that I, as well as any member of my household, have NOT traveled outside of the country, or to any city outside of our own that has not been considered a “hot spot” for COVID -19 infections within the past 30 days.*
- Yes
- No
I understand that Kellie Campbell and Clear Solutions Acne & Skin Care Clinic CAN NOT be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.*
- Yes
- No
*If you have any symptoms or answer NO to any of the questions, I would need to cancel your appointment. If I do not receive this signed form the morning prior to your appointment, I will have to reschedule your appointment.

By signing below I agree to each above statement and release Kellie Campbell and Clear Solutions Acne & Skin Care Clinic from any and all liability for the unintentional exposure or harm due to COVID-19.

I, Kellie Campbell, agree that I abide by these same standards and affirm the same. I also affirm that I have taken an advanced Committed to Health & Safety Infection Control 2 hour online course on 4/30/2020.

This form will not have to be signed for future appointments unless any of the above statements should change. If so you will promptly notify me and I will need to cancel your appointment for the safety of any clients coming to the clinic and myself
Full Name*
Full Name
Date*
Date Format: MM slash DD slash YYYY

Pin It on Pinterest