Name *

First Name

Last Name

Date *

MM

DD

YYYY

Acknowledgement *

I acknowledge the contagious nature of the coronavirus/COVID-19 virus and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Hand & Eye Fine Arts, DBA Tattoos By Serena LLC, has put in place sufficient preventative measures to reduce the spread of coronavirus/COVID-19. I further acknowledge Hand & Eye Fine Arts, DBA Tattoos By Serena LLC cannot guarantee that I will not become infected with the coronavirus/COVID-19 virus. I understand that the risk of becoming exposed to and/or infected by the coronavirus/COVID-19 virus may result from the actions, omissions, or negligence of myself and others, including but not limited to, tattoo studio staff and other clients and their families. I voluntarily seek services provided by Hand & Eye Fine Arts, DBA Tattoos By Serena LLC and acknowledge that I am increasing my risk to exposure to the coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread of COVID-19 while attending my appointment.

Yes, I acknowledge the above statements

No, I do not acknowledge

Question #1 *

I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

I do not have these symptoms

I have symptoms

Question #2 *

I have not travelled internationally within the last 14 days.

Correct

No, I have travelled internationally

Question #3 *

I have not travelled to a city or state with high outbreaks of Covid-19 in the last 14 days. If in doubt, please consult the CDC.

Correct, I have not.

No, I have travelled to a highly contagious city/state.

Question #4 *

I do not believe I have been exposed to someone with a suspected and/or confirmed case of the coronavirus/COVID-19 virus.

Correct

No, I believe I have been or may have been exposed.

Question #5 *

I am following all CDC recommended guidelines and limiting my exposure to the coronavirus/COVID-19 virus.

Yes, I am being safe and following CDC guidelines.

No, I have not.

Liability Waiver *

I hereby release and agree to hold Hand & Eye Fine Arts, DBA Tattoos by Serena LLC harmless from, and waive on behalf of myself and my heirs, and any personal representatives and any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and or property that may be caused by any act, or failure to act by the tattoo studio, or that may otherwise arise in anyway in connection with any services received from Hand & Eye Fine Arts, DBA Tattoos By Serena LLC. I understand that this release discharges Hand & Eye Fine Arts, DBA Tattoos By Serena LLC from any liability or claim that I, my heirs or any personal representative may have against the studio with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to any services received from Hand & Eye Fine Arts, DBA Tattoos by Serena LLC. This liability waiver and release extends to the Studio together with all owners, partners and employees.

Yes, I agree to the statements above.

No, I do not agree.