COVID-19 Release Form

Covid-19 Screening Form

Your health and well- being is my number one priority. Please complete this brief CoVid-19 wellness screening prior to leaving your home for your scheduled session. I appreciate your voluntary support in helping to keep myself (and my newborn at home) and the community safe and healthy! If you feel off with any symptoms or answer YES to any of the below questions, STAY HOME and I will be happy to reschedule you.

Full Name

First Name

Last Name

Phone

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Have you personally tested positive for CoVid-19 in the past 14 days or are you awaiting results from a CoVid test?

I confirm that I have received both Covid vaccine and booster. I understand that Clean Beauty Quyen is accepting fully vaccinated and boosted clients only. I agree to show proof of my vaccinations.

I confirm that I am not presenting any of the following symptoms related to Covid-19: Fever of 100 F or higher • Unexplained body aches or • Recent loss sense of smell or taste • Unexplained sores or rashes on soles of feet or hands • Unusual fatigue • Non-allergy related runny nose

I confirm that I have not had any contact with a Covid-19 related patient or someone who is exhibiting Covid-19 like symptoms in the past 14 days.

I confirm that if I am visiting NYC or have travelled domestically or internationally by commercial airlines, bus, train or car in the past 14 days I must submit a negative Covid test result 24 hours before my scheduled appointment and show proof.

I have truthfully answered the Covid-19 Release Form. I understand that answering this form falsely or withhold information regarding the true nature of my health can result in legal action to be taken by Quyen Ly of Clean Beauty Quyen. I understand that I have to comply with Clean Beauty Quyen guidelines and protocols. If I fail to comply Quyen has the right to refuse or stop my service. All of my questions have been answered to my satisfaction and I consent to the terms established by Clean Beauty Quyen. I understand that Clean Beauty Quyen may cancel my booked appointment depending on the completion of the Covid-19 Health Questionnaire. I acknowledge the potential risk of contracting COVID-19 while heading to Clean Beauty Quyen. I understand that skin treatments involves close physical proximity over an extended period of time, I voluntarily agree to accept services done by Quyen Ly at Clean Beauty Quyen. I agree and hereby release Quyen Ly of Clean Beauty Quyen of all liability associated with the potential risk to Covid-19.

Waiver/Release Statement

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