A. PERRY HOMES COVID-19 CONSENT FORM

These are uncertain times and much information has been presented, shared, and debated. We at A. Perry Homes take your safety seriously and treat it as our top priority. We are fortunate to design, build, and remodel some of the most magnificent homes in the world for some pretty special people, our valued clients. For generations, people have trusted us with what matters most to them, their family, and home. We care deeply about your safety.
 
For your safety, as well as the safety of our employees and other clients, consultants, vendors, and subcontractors who may visit our offices or work in your home, we are taking extra precautions according to the guidelines provided by the CDC and the State of Illinois. This includes the use of face coverings, social distancing, enhanced cleaning and disinfection procedures in our offices, and required completion of this consent form by anyone we will be in contact with.

Please take a moment and complete this form prior to your appointment. Please pardon the inconvenience and understand that we are doing our best to be vigilant for your best interests. 

Name:*
E-mail:*

Please review the following list of symptoms commonly associated with COVID-19:

  • Cough
  • Temperature above 98.7 degrees      
  • Headache   
  • Loss of taste or smell
  • Shortness of breath or difficulty breathing
  • Muscle Pain
  • Sore throat
I understand the above symptoms and affirm that I, and/or any members of my household, do not currently have symptoms and have not experienced any symptoms listed above WITHIN THE PAST 14 DAYS:*
I affirm that I, and/or any members of my household, have not been diagnosed with COVID-19 WITHIN THE PAST 30 DAYS:*
I affirm that I, and/or any members of my household, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 14 DAYS:*
I affirm that I, and/or any members of my household, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 14 DAYS:*
I further acknowledge that A. Perry Homes has put in place preventative measures to reduce the spread of COVID-19 and other communicable diseases:*
I affirm that I, and all members of my household, are following CDC and State of Illinois recommended guidelines and limiting our exposure to COVID-19:*
I acknowledge the contagious nature of COVID-19 and other communicable diseases and that the CDC and other public health authorities recommend face coverings, social distancing, and capacity limitations:*
I further acknowledge that A. Perry Homes cannot guarantee that I will not become infected with the COVID-19 or other communicable diseases. I understand that the risk of becoming exposed to and/or infected by COVID-19 or other communicable diseases may result from the actions, omissions, or negligence of myself and others, including, but not limited to, A. Perry Homes staff, and other A. Perry Homes clients and their families:*
I voluntarily seek services provided by A. Perry Homes and acknowledge that I am increasing my risk to exposure to COVID-19 or other communicable diseases. I acknowledge that I must comply with all recommended procedures to reduce the spread while in the A. Perry Homes offices.*
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with the services provided by A. Perry Builders, LLC or A. Perry Designs and Builds, PC. I hereby release, covenants not to sue, discharge, and hold harmless both A. Perry Builders, LLC and A. Perry Designs and Builds, PC, their employees, agents, and representatives, of and from the claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agrees that this release includes any claims based on the actions, omissions, or negligence of A. Perry Builders, LLC or A. Perry Designs and Builds, PC, their employees, agents, and representatives, whether a COVID-19 or other communicable disease infection occurs before, during or after the services provided.*
Date:*
Phone #:*
Digital Signature: please type your full name below. By typing and submitting, this serves as a Digital Signature and verifies that you fully agree to our safety policy for our services. This digital signature holds the same authority as a handwritten one :*