Coronavirus

COVID19 Wellness Form

REQUIRED FOR EACH SPA VISIT. Please complete this form THE DAY BEFORE your scheduled appointment. Thank you!
Our highest priority is to keep all of our clients and staff as safe as possible. Some of our clients are vaccinated, some partially vaccinated and others will not be getting vaccines. Due to the infectious Delta variant, ALL CLIENTS are asked to wear a mask into the spa.
Name *
In the past 2 weeks have you tested positive for COVID or received a vaccine / vaccine booster? *

YES NO
Have you received a COVID vaccine in the last 2 weeks? (Vaccines are not required) *

Yes No
If "yes" please explain (write N/A for NO) *
Did you receive a vaccine in the last 7 days? (write N/A for NO). Please text us at 704.890.1071 to discuss your treatment if you've been recently vaccinated. *
Are you experiencing COVID symptoms (cough, shortness of breath, fever, chills, body aches)? *

YES NO
Are you feeling ill or have there been ANY change in your health or medications since your last visit to the spa? *

YES NO
If "yes" please explain changes (write N/A for NO) *
PLEASE READ AND CHECK EACH BOX TO CONFIRM YOU UNDERSTAND AND AGREE *

I will wear a face mask regardless of my vaccination status. I will wear a camisole (women) or tank top (men). If my health changes, I will notify the spa immediately.
I CONFIRM I HAVE ANSWERED ALL QUESTIONS AND STATEMENTS WITH HONESTY. *
Questions or Comments
I understand personal contact with others during the Covid-19 outbreak involves a certain degree of risk that could result in illness, disability or death. After considering the risks and in consideration of ÉCLAT Skin Confidence Spa (ECLAT) willingness to conduct my spa service, I hereby release and hold harmless ECLAT, its owners and employees from any liability allegedly arising out of my spa service including but not limited to claims based on allegations of negligence. I intend this release to be the broadest allowed by law. *

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COVID19 Wellness Form