Do you have a fever or above normal temperature?*

Yes

No

Have you experienced shortness of breath or had trouble breathing?*

Yes

No

Do you have a dry cough?*

Yes

No

Do you have a runny nose?*

Yes

No

Have you recently lost or had a reduction in your sense of smell?*

Yes

No

Do you have a sore throat?*

Yes

No

Have you been in contact with someone who has tested positive for COVID‐19?*

Yes

No

Have you ever tested positive for COVID‐19?*

Yes

No

what date was your negative test result?*

Have you been tested for COVID‐19 and are awaiting results?*

Yes

No

Have you traveled outside the United States by air or cruise ship in the past 14 days?*

Yes

No

Have you traveled within the United States by air, bus or train within the past 14 days?*

Yes

No

Client First and Last name*

Email*

Phone*

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 preventable 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. I give my consent to receive treatment from this practitioner.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Client Signature or that of Legal Guardian for a Minor 18 and under.

Signature*

Reset

Services

Services

Book your appointment online or get in touch with us by phone by calling Derma Renew Spa in Rochester NY We can be reached by phone at 585‐233‐6018 or online through our secure contact page.