**This form will be filled out on an iPad, at my salon suite, before your appointment**

Precautionary Coronavirus Liability Release Form

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, I’m taking extra

precautions with the intake of each client, including a health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.


Symptoms of COVID-19 include: Fever, Fatigue, Dry cough, Shortness of breath, chills, muscle pain, loss of taste or smell, sore throat and headache.

I agree to the following:

❏ I understand the above symptoms and affirm that I, as well as all household members,

do not currently have, nor have experienced the symptoms, listed above within the last

14 days.

❏ I affirm that I, as well as all household members, have not been diagnosed with

COVID-19 within the last 30 days.

❏ I affirm that I, as well as all household members, have not traveled outside of the

country, or to any city outside of our own that is or has been considered a “hot spot” for

COVID-19 infections within the last 30 days.

❏ I understand that this business (Michelle Benjamin Mind & Body) and Michelle Benjamin, cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

❏ I agree to have my temperature taken and recorded here:_______


By signing below, I agree to each above statement and release Michelle Benjamin Mind & Body LLC from any and all liability for the unintentional exposure or harm due to COVID-19.

PRINT NAME:_______________

SIGNATURE:________________ DATE


I, Michelle Benjamin, agree that I abide by these same standards and affirm the same. I also affirm that I have improved and expanded my sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.