Name *

First Name

Last Name

Phone *

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I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. *

Yes

No

I voluntarily seek services provided at Quiet Canary 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 while attending my appointment. *

Yes

No

I attest that I am not experiencing any symptom 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. *

Yes

No

I attest that I have not been instructed to self isolate by Public Health *

Yes

No

I attest that I will inform Quiet Canary if I have any stymptoms of or have Covid-19 within 14 days following the procedure. *

Yes

No

I hereby release and agree to hold my service provider and Quiet Canary harmless from, and waive on behalf of myself, my heirs, and any personal representatives 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 of the studio, or that may otherwise arise in any way in connection with any services received from Quiet Canary. I understand that this release discharges Quiet Canary and their service providers from any liability or claim that I, my heirs, or any personal representatives 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 Quiet Canary. This liability waiver and release extends to the studio together with all owners, partners, and employeess *

Yes

No