• 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
  • *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
  • Date Format: MM slash DD slash YYYY

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