Coronavirus Intake form for Massage Therapists

Skin Deep Day Spa, LLC

1216 Wildwood, Suite C, Jackson, MI 49202

517.990.9088 - skindeepspajackson.com

For the safety of everyone...

Until further notice, please complete this form least 24 hours prior to your service appointment with us at Skin Deep Day Spa, LLC. Please ensure the information you provide is accurate, complete, and true to the best of your knowledge. If you experience any symptoms of COVID-19, please seek medical attention and immediately contact Skin Deep Day Spa, LLC to reschedule your appointment.

Name *

First Name Last Name

Date *

Date

Phone Number *

Area Code Phone Number

Email *

example@example.com

I understand that I am required to fill the COVID-19 Release form 1 day prior to each service scheduled at Skin Deep Day Spa. I understand that if I fill this out more than 1 day prior to my service that it will not be valid and I will need to fill out a new form. *

Yes No

I certify and agree that the information provided by me herein is accurate and true to the best of my knowledge and belief. *

YES NO

Have you had COVID-19? *

YES NO

When did you have COVID-19? blanks

In the past 30 days, I have experienced the following... If you answer yes to any of these symptoms, you will be asked to reschedule your appointment *

Yes

No

Fever 100°F +

Unexplained body aches or pain

Coughing

Sore throat

Shortness of breath

Chills with or without body aches

Recent loss of sense of smell or taste

Unexplained sores on soles of feet

Unusual fatigue

Congestion or Runny nose (unrelated to allergies)

Headache (out of ordinary)

I understand that I CANNOT receive a treatment if I have been in direct contact with anyone that has been diagnosed with COVID-19 within the last 30 days. *

YES NO

I understand that if I am higher risk for serious illness (including, but not limited to, COVID-19), then it is my choice to receive services from Skin Deep Day Spa, LLC, and that I do so entirely at my own risk. It is my responsibility to consult with my physician prior to receiving any and all services from Skin Deep Day Spa, LLC. *

YES NO

I aﬃrm that I have not been diagnosed with, nor exhibited any symptoms of, COVID-19 within the last 14 days. I have been symptom free for 48 hours. I further aﬃrm that no members of my household have been diagnosed with, nor exhibited any symptoms of, COVID-19 within the last 30 days. *

YES NO

I affirm that I have NOT traveled outside of the country or to any location, that is or has been considered a "hotspot" for COVID-19 infections within the last 30 days. I agree to check the CDC Travel Health Notices list prior to visiting Skin Deep Day Spa, LLC. *

YES NO

I affirm that I have NOT traveled on an airplane within the past 14 days. *

YES NO

CDC Travel Health Notices List can be found at https://www.cdc.gov/coronavirus/2019-ncov/travelors/map-and-travel-notices.html

I understand that Skin Deep Day Spa, LLC, and its employees shall not be deemed liable for any exposure to COVID-19 or any other contagion caused by misinformation on this form or the health history provided by each client of Skin Deep Day Spa, LLC. *

YES NO

For more information on whether you may be considered at higher risk for serious illness 1 (including COVID- 19), please visit https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk-old.html COVID-19 or any other contagion caused by misinformation on this form or the health history provided by each client of Skin Deep Day Spa, LLC.

I understand that COVID-19 is a highly contagious virus that is spread from person to person. In addition to long-held and explicit sanitation measures that Skin Deep Day Spa, LLC, has always adhered to, new preventative measures have been put into place to further reduce the risk of spreading COVID-19. However, these best practices still oﬀer no guarantee regarding your safety and/or potential risk of being infected. I understand both the known and potential dangers of receiving services at Skin Deep Day Spa, LLC, in light of the COVID-19 pandemic and acknowledge that receiving services from this business may, (despite reasonable eﬀorts by Skin Deep Day Spa, LLC, to mitigate such dangers) result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability, and/or death. *

YES NO

Given the nature of the services provided by Skin Deep Day Spa, LLC, I understand and acknowledge both the known and potential risks of receiving services at Skin Deep Day Spa, LLC, in light of the COVID-19 pandemic and acknowledge that receiving services from this business may (despite reasonable eﬀorts by Skin Deep Day Spa, LLC, to mitigate such dangers) result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability, and/or death. *

YES NO

By signing this form, I hereby release, hold harmless, waive, discharge, and covenant not to sue Skin Deep Day Spa, LLC, its directors, oﬃcers, employees, volunteers, and agents with respect to any liability for any injury, loss, and/or damage (including, but not limited to, illness or death) that I may sustain related to COVID-19. I further hereby knowingly consent to receive treatment from Skin Deep Day Spa, LLC *

YES NO

I have read and and understand the terms of this COVID-19 Information and Release Form, and knowingly and voluntarily agree to its terms. This release shall be binding on my estate, heirs, executors, administrators, successors, agents, and assigns, as well as any other party asserting a claim on my behalf. *

YES NO

I understand the following cancellation policy: Cancellation of appointments with less than a 24-hour notice or no shows are charged 50% of the missed service/s. The credit card on file is charged the cancellation fee. *

Yes No

Date *

Date

Signature *

Clear

Parent or Guardian Signature if under the age of 18 years old.

Clear

COVID-19 INFORMATION AND RELEASE FORM