COVID-19 Questionnaire & Liability Release Form

Due to the 2019-2020 outbreak of COVID-19, we are taking extra precautions with the intake of each client. Our main goal is to protect our staff and our clients as much as possible. New safety protocols are being implemented by our facility: frequent disinfection and cleaning, minimal contact, keeping 6 ft. distance whenever possible. Our business and technicians are taking all precautions to keep you safe during this time.

We ask that you help keep yourself and us safe by reviewing and completing the following form:


Symptoms of the novel coronavirus include (but not limited to):

  • Fever

  • Dry Cough

  • Sore Throat

  • Muscle Pain

  • Headache

  • Fatigue

  • Chills

  • Difficulty Breathing (advanced cases)

  • Loss of Taste or Smell

Please initial the following:

Upload

Thanks for submitting!