Consent to Service

Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), The Fairy Tan Mother is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the Virginia Department of Professional and Occupational Regulation guidance.

Symptoms of COVID-19 include:

  • Fever

  • Fatique

  • Dry Cough

  • Difficulty Breathing

 

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 PAST 30 DAYS.

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS.

I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS.

I understand that The Fairy Tan Mother and Gretchen Sutphin cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

 

By signing below, I agree to each statement above and release The Fairy Tan Mother and Gretchen Sutphin from any and all liability for the unintentional exposure or harm due to COVID-19.

Consent of Services Form

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