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Covid-19 Treatment Consent Form

Consent*
I enter my name below to acknowledge I knowingly and willingly consent to receive treatment during the COVID-19 pandemic.*
Name*
First Last
Consent*
I understand the COVID-19 virus and variants have a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has the virus and who does not.*
Consent*
Hannah Sowd Skin Care has taken precautions to create a safe environment. It is unclear how long ultra-fine particles may linger in the air and it is unclear if these may transmit the COVID-19 virus.*
Consent*
I confirm that I am not presenting any of the following symptoms of COVID-19 :  *
* Fever  

* Shortness of Breath  

* Loss of Sense of Taste or Smell  

* Dry Cough  

* Fatigue 

* Sore Throat
(initial)*
Consent*
I understand the CDC recommends social distancing of at least 6 feet which is not possible during the skincare or massage treatment I am about to receive.*
Consent*
I understand I may encounter other clients while at Hannah Sowd Skin Care and it is my responsibility to maintain a 6 foot distance.*
(initial)*
Consent*
I verify that I have not tested positive for the COVID-19 virus in the past 30 days.*
(initial)*
Consent*
I verify that I have not traveled by commercial airline within the past 14 days.*
(initial)*
Are you fully vaccinated for COVID-19?*
Are you fully vaccinated for COVID-19?
Consent*
I will not hold Hannah Sowd Inc, Hannah Sowd Skin Care, or any employee liable if I test positive for the COVID-19 virus after my treatment today.*
I understand it may be necessary to share my name and contact information with the city or state health department in the event that a client or practitioner at this facility tests positive for COVID-19.

My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.
Name
First Last
Date
MM slash DD slash YYYY
Comments
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