Neatness Counts KC, LLC

Neatness Counts KC, LLC

COVID-19 Agreement and Certification

Client:

Appointment Date:

Neatness Counts KC, LLC (NCKC) requires clients and employees to take proper precautions as outlined by the Centers for Disease Control (CDC) when working together. This includes wearing a face mask and maintaining social distance of six feet or more. If you or a member of your household are not feeling well near the time of your scheduled appointment, we ask that you notify us to reschedule. NCKC will do the same if an employee is not feeling well.

Each person present during an appointment individually acknowledges that the novel coronavirus (COVID-19) represents a serious health threat to persons exposed to it, and that all persons present during this visit are relying on the truthfulness and accuracy of the certifications made herein.

Each person present during this visit individually certifies that to the best of their knowledge, information, and belief, neither they nor a member of their household with whom they live:

            1. Has been diagnosed (tested positive) with COVID-19.

           2. Has a test pending for COVID-19.

            3. Is under quarantine directed by a healthcare provider due to COVID-19 concerns.

            4. Has had contact within the last 14 days with someone diagnosed with COVID-19. 5. Has had contact with someone who had contact within the last 14 days with someone diagnosed withCOVID-19.

            • I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved.

            • I agree to immediately notify NCKC in the event that I, a member of my household, or visitors to my household, exhibit symptoms or tests positive for COVID-19 within 14 days following an appointment. Likewise, NCKC will immediately notify you if an employee that has worked with you develops symptoms or tests positive for COVID-19 within 14 days following an appointment.

          • I understand that my name and contact information might be shared with the state health department if I, or a NCKC employee, tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

          •Employees, Vendors, or Clients hold NCKC harmless and all work performed by Employee or Vendor is voluntary and not required by NCKC.

          •I (see names below) have read and answered honestly and agree to the conditions set forth in this document and have voluntarily disclosed health information.

PLEASE SIGN TO INDICATE YOUR CERTIFICATION OF ALL OF THE ABOVE AS TO YOURSELF:

Name:                                                                                 Signature:                                                                                      Date:

1.         ________________________________                         _________________________________              _______________

2.         ________________________________                         _________________________________              _______________

3.         ________________________________                         _________________________________              _______________

4.        ________________________________                          _________________________________              _______________

END OF DOCUMENT