DAY SPA & BOUTIQUE

SCREENING FORM

Please complete our COVID-19 Screening and Consent to Treat Form: 

This form is required to be completed no less than 12 hours and no more than 24-hours before your scheduled appointment.

Have you had a fever in the last 24 hours of 100.4 F or above?*
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
Do you now, or have you recently had, any chills, new loss of taste or smell, or new rashes or lesions?*
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*
I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility 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*
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 and give consent to receive massage from this practitioner. *
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