Microcurrent Form

Please fill out this form as fully as possible.

  • Date Format: MM slash DD slash YYYY
  • These questions are relevant to your skin health and may be contraindications for treatment, please answer thoroughly.

  • Check all that apply.
  • Although every precaution will be taken to ensure your safety and wellbeing before, during and after your microcurrent treatment, please be aware of the following information and possible risks.

    By marking 'Yes' you acknowledge your understanding.
  • 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 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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