​​Print and sign the areas highlighted in green below. 

Please bring with you to your appointment.​​

Image Care Electrolysis

Due to the 2019-2020 Pandemic of the Covid – 19,

I am taking extra precautions with the intake of each client, health history review, as well as sanitation and  additional disinfecting practices.
Common symptoms of COVID –19 may include some of the following: (but not limited to)
• Dry cough Other possible symptoms include:
• Fatigue/tiredness Sore throat, Body aches/pain, headache
• Fever
• Shortness of breath


I _____________________________agree to the following:
• I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days.
• 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, 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, Image Care Electrolysis cannot be held liable for any exposure to the virus or any other contagion cause by misinformation on this form or the health history provided by each client. Furthermore, I agree to not hold Image Care Electrolysis or any associates if I do contract COVID-19 or any other contagion as I have decided to come here on my own free will.
By signing below, YOU agree to each above statement and release Image Care Electrolysis and business from any and all liability for the unintentional exposure or harm due to COVID-19.

Signature_________________________Date__________