Cryotherapy Consultation and Consent Form

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Covid-19 Screening Questions

To ensure the safety of all parties and to stop the further spread of the Covid-19 virus, please complete the below questions as honestly and accurately as possible prior to your appointment date.

1. Have you, or anyone in your household, had Covid-19 in the last 14 days? *

Please give detail: *

2. Are you, or anyone in your household, awaiting test results for Covid-19? *

Please give detail: *

3. Have you, or anyone in your household, had any of the following symptoms in the last 14 days: Continuous cough, Fever, High temperature, Loss of sense of taste, Loss of sense of smell? *

Please give detail: *

4. Have you, or anyone in your household, been in contact with anyone with confirmed Covid-19 in the last 14 days? *

Please give detail: *

5. Have you, or anyone in your household, travelled outside the US in the past 14 days? *

Please give detail: *

6. Have you received a Covid-19 vaccine? *

Which vaccine did you receive? *

Have you received one or two doses? *

First Dose: *

Second Dose: *

Appointment Guidance

If you have answered yes to any of the above questions we will be in contact as you may need to reschedule your appointment with us.
Please only attend at your appointment time.
Please ensure you are on time - if you are late this may result in your appointment being cancelled.
Please attend your appointment unaccompanied.
Please limit the personal possessions you bring with you.
Please wear a face mask/covering to your appointment.
Upon arrival please wait until you are called forward to reception.
Upon arrival please use the hand sanitiser provided.
Please maintain social distancing where possible.
If you experience Covid-19 symptoms after your appointment please contact us immediately.

Please tick each statement to show your understanding and agreement. *

I’m willing to get my body temperature checked before beginning my salon/clinic services. If my temperature is above 37 degrees celsius I agree to not visit the salon/clinic for the next 14 days. I agree not to visit the salon/clinic for any of the services provided if I have the symptoms of Covid-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below I confirm that I understand and agree to all terms and statements in this form.

Client Signature: *

Tap or click on the signature above to sign

SUBMIT

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Cryotherapy Consultation and Consent Form

Covid-19 Screening Questions

Client Details

Medical History

Treatment Information

Consent