Ageless Perfection Skin Care Studio FLU/RSV &    COVID-19 Screening Form & Liability Waiver
By completing and submitting this form, you are knowingly and willingly consenting to having aesthetic/skincare   services performed during the COVID-19 Pandemic. You agree to adhere to all safety and sanitation protocols now required by the Ageless Perfection Skin Care Studio.
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Email *
First Name *
Last Name *
Contact Cell/Phone Number *
Street Address, City, State Zip *
My Baseline pre-visit temperature must be below 99 degree Fahrenheit to receive a service. I understand  my temperature will be taken upon arrival for my appointment and recorded prior to entering building. *
Required
Temperature at appointment (To be completed by Provider):
I am aware and understand that I am REQUIRED to wear a mask when entering the building and it is to remain on until instructed to remove.  I understand that I will be given a mask to wear if I arrive without one.  If I refuse to wear mask, I will be instructed to leave. *
Required
I am aware that testing for the COVID-19/FLU/RSV in some areas is limited, the virus may have a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it . *
Required
I also acknowledge and understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting one of these viruses should it be present. *
Required
I confirm that none of the following FLU/RSV or COVID-19 signs or symptoms have been present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Diarrhea/Nausea, Muscle Aches/Pain, Headache, Pink Eye, Congestion, Pressure in Chest or been in close contact with a person who is lab confirmed to have COVID-19.  IF YOU HAVE HAD ANY OF THESE SYMPTOMS, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
Required
I affirm that I have not been exposed to anyone that has been diagnosed with the FLU/RSV or COVID-19 within the past 7 days inside or outside of the United States.   IF YOU HAVE BEEN EXPOSED TO the FLU/RSV OR COVID-19, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
Required
I affirm that I have not traveled domestically (outside of my state) or internationally (outside of the United States) within the past 14 days.  IF YOU HAVE TRAVELED OUTSIDE THE UNITED STATES OR INTERNATIONALLY, TEXT/CALL 817.888.5247 IMMEDIATELY. *
Required
I affirm that I have not been in a large crowd (more than 5 people that do not live in the house with me) not wearing a mask and staying 6 ft apart.   IF YOU HAVE BEEN IN A CROWD AS DESCRIBED ABOVE, TEXT/CALL 817.888.5247 IMMEDIATELY. *
Required
Do you suffer from allergies? If yes, explain what are your allergy symptoms. If no, then put "Not Applicable or N/A" below. *
I agree by providing my name below, I am rendering my signature electronically  in acknowledgement of the  completed statements on this form and that all information is accurate as of the date of this form.  Type your name below. *
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A copy of your responses will be emailed to the address you provided.
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