COVID-19 Health Screening and Liability Waiver Release Form

Let us do this part
Today's Date:
Tue Oct 27 2020 03:00
Practioner:*
I consent to receive a tattoo or piercing service(s) during the COVID-19 outbreak.
I understand there is much to learn about the newly emerged COVID-19 including how it spreads and is transmitted
I understand that based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19.
I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
I understand that due to the unknowns of this virus, and the nature of the procedures performed within any tattoo or piercing facility, that I have an increased risk of contracting the virus if I have a body art procedure performed on me during the COVID-19 outbreak.
I understand that the symptoms listed below are representative of COVID-19:
FEVER, DRY COUGH, SHORTNESS OF BREATH, HIGH BODY TEMPERATURE, BLUISH LIPS AND FACE

I confirm that I do not display or currently have ANY of the symptoms that are representative of COVID-19, which are outlined above.
I confirm, to the best of my knowledge, that I have not had any close contact with an individual diagnosed with COVID-19 in the past 14 days.
Please read and answer
Y
N
*
Do you have a fever or have you felt hot or feverish in the last 14-21 days?
Y
N
*
Are you currently experiencing shortness of breath or difficulties breathing?
Y
N
*
Do you currently have a cough?
Y
N
*
Are you currently experiencing any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Y
N
*
Have you recently experienced loss of taste or smell?
Y
N
*
Are you in contact or have you recently had contact with any confirmed COVID-19 positive patients?

(clients who are well but who have sick family members at home are asked to reschedule at a later time, when all members of your household are confirmed healthy)
Y
N
*
Are you over 60?

(clients who are over 60 are encouraged to refrain from getting tattooed or pierced during the pandemic)
Y
N
*
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorder?

(clients with compromised immune systems are encouraged to refrain from getting tattooed or pierced during the pandemic. We may require a doctor's note informing us whether it is safe to tattoo or pierce you)
Y
N
*
Have you traveled out of the region/state/country in the past 14 days?
Y
N
*
I HAVE ANSWERED ALL QUESTIONS HONESTLY AND TO THE BEST OF MY ABILITY. I UNDERSTAND THAT IF I HAVE MISREPRESENTED MY HEALTH STATUS OR THAT OF MY IMMEDIATE HOUSEHOLD IN ORDER TO GET TATTOOED OR PIERCED, I MAY BE HELD LIABLE IN A COURT OF LAW
Positive responses to any of these questions will likely indicate a deeper discussion with your artist before proceeding with your body modification
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Personal Info
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.
Legal Name:*
Prefered name:
Address:
Date of birth:*
Phone #:*
Email:*
Signature:*