COVID-19 Information & Liability Waiver Name First Last Do you have a fever, or have you felt hot or feverish in the past 14 days?* Yes No Are you having shortness of breath or other difficulties breathing?* Yes No Do you have a cough?* Yes No Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue?* Yes No Have you experienced recent loss of taste or smell?* Yes No Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?* Yes No Have you or anyone in the household traveled outside Vermont recently?* Yes No Have you been in contact with anyone in the last 14 days who has traveled outside Vermont?* Yes No Have you been fully vaccinated against COVID-19?* Yes No COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected. Consent for Treatment I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto.If you come down with any symptoms of COVID-19 prior to your treatment. Please cancel your appointment in order to prevent the possible spread of the virus. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my, or others' health. It is my responsibility to inform Skin Solutions of any changes in medical history prior to my skincare treatment. I give my consent to receive treatment from this practitioner.* Yes Services Select a Treatment Specials Save on Skincare