Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

I agree to the following: *

I affirm that I, as well as all household members have not been diagnosed with COVID-19 within the last 30 days

I understand that the above symptoms and confirm that I, as well as all household members do not currently have, nor have experienced any symptoms listed above within the last 14 days

I affirm that, I as well as all household members, have not traveled outside of the country or to a city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days

I understand that this business and my Aesthetician/Nurse cannot be held liable for any exposure to the virus or any other contagion cause by misinformation on this form or the health history provided by each client

I agree to not hold Skin Oasis or it’s associates if I contract COVID-19 or any other contagion as I have decided to come here on my own free will.

Date *

MM

DD

YYYY