Coronavirus Self Declaration Form

Coronavirus Self Declaration Form

For the health and safety of our facility and staff, declaration of illness is required. Be sure that the information you give is accurate and complete. Please re-schedule and seek immediate medical attention if you have any of the COVID-19 symptoms.
Name*

First NameLast Name
Have you travelled out of the country in the last 5 days?*

YesNo
Have you been in contact with people being infected, suspected or diagnosed with COVID-19 in the last 72 hours?*

YesNo
Have you been in a group of 20 or more and were not socially distant? If yes, please email/text your LMT to ensure you both are comfortable proceeding with your session.

YesNo

Please state whether you've experienced/are experiencing the following*

By signing below, I declare that the above information is true and correct. I hereby release Specialized Bodyworks' Therapists, Estheticians, and Pilates Instructors, from any and all libilility for the unintentional exposure or harm due to COVID-19.
Today's Date

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Date
Signature*

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