COVID-19 Liability Release Waiver

Signature Required Prior to Every Scheduled Appointment

- Due to the 2019-2020 outbreak of the Coronavirus (COVID-19), Essential Esthetics is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the Arkansas Board of Cosmetology.
- Symptoms of COVID-19 include:
  - Fever
  - Fatigue
  - Dry Cough
  - Difficulty Breathing
Have you had a fever of 100.4 F or greater in the last 2 days?*
- Yes
- No
Do you have a cough, difficulty breathing, sore throat, or loss of taste or smell?*
- Yes
- No
Have you had contact with a person known to be infected with COVID-19 within the past 14 days?*
- Yes
- No
(Those answering "yes" to any of the above shall have their services postponed for 14 days. Services shall not be performed on clients who show any sign of illness such as fever, cough, or runny nose. Employees/licensees shall be pre-screened with both the standardized questionnaire and a daily temperature check. Any employee with a temperature of 100.4 F or greater will not be allowed to work.)
- I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above WITHIN THE LAST 14 DAYS.
- I affirm that I, as well as all household members, have not been diagnosed with COVID-19 or have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS.
- I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS.
- I understand that Cynthia Cantele & Striving for Excellence Holding Co, dba Essential Esthetics and his/her licensees or assignees cannot 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.
- Cynthia Cantele & Striving for Excellence Holding Co, dba Essential Esthetics and his/her licensees or assignees is following these enhanced procedures to prevent the spread of COVID-19:
  - Invoicing options will be available if clients prefer contactless checkout.
  - Additional time included between appointments to prevent client contact with each other.
  - Esthetician will be wearing face covering and you are asked to as well, service permitting. Please bring one with you.
  - We are limited on the amount of people we can have in the building at one time. We ask that you wait to be let into the building by your esthetician.
  - We will check your temp via a no contact thermometer before entering the building.
  - Once inside, you will be asked to wash your hands & will be given you some hand protection to apply.
  - No guests are permitted to be with you during your appointment.
  - All persons in the building are required to maintain physical distancing of at least 6 ft while services are being rendered.
  - The vulnerable population is asked to wait until further notice for appointments. (i.e. those over the age of 65 or with chronic health conditions)
  - Your esthetician will thoroughly clean hands and wear gloves during treatments
  - All treatment items will be disinfection according to the manufacturer's directions
- By signing below, I agree to each statement above and release Cynthia Cantele & Striving for Excellence Holding Co. dba Essential Esthetics and his/her licensees or assignees from any and all liability for the unintentional exposure or harm due to COVID-19. Cynthia Cantele agrees to abide by these standards and affirms the same.
Patient Name*
First Last
Date*
Parent or Guardian (if patient is under 18)
First Last
Date

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COVID-19 Liability Release Waiver

COVID-19 Liability Release Waiver

COVID-19 Liability Release Waiver

**Signature Required Prior to Every Scheduled Appointment**

Signature Required Prior to Every Scheduled Appointment