COVID19 Wellness Form
MUST BE COMPLETED THE DAY BEFORE EACH SPA VISIT.
Name
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When is your scheduled appointment date? (Please do NOT continue unless your appointment is in the next 24 hours)
*
-
Month
-
Day
Year
Date
Have you traveled out of state or visited one of the COVID-19 affected countries in the last 14 days?
*
Yes
No
If yes, where did you travel to? (Indicate "none" if no travel)
*
Have you tested positive for COVID or been in close contact with a confirmed case of Coronavirus?
*
YES
NO
If "Yes" please explain (write N/A for NO)
*
Are you experiencing COVID symptoms (cough, shortness of breath, fever, chills, body aches)?
*
YES
NO
Has there been any change in your health or medications since your last visit to the spa?
*
YES
NO
If "yes" please explain health or medication changes (write N/A for NO)
*
PLEASE READ AND CHECK EACH BOX TO CONFIRM YOU UNDERSTAND AND AGREE
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I will wear a face mask upon entering the spa, and will keep it on until my esthetician informs me it is okay to remove it.
My temperature will be taken with a no-contact thermometer upon entering the spa, and I will be asked to reschedule if I have a reading of 100.4 or above.
I will practice social distancing while in the common areas of the spa building.
I will wear a tank top and bring a cover up to my appointment as spa wraps and blankets are temporarily suspended during treatment.
If I feel uncomfortable proceeding with my appointment for any reason, or if my health or risk of exposure changes, I will notify the spa immediately and reschedule my appointment.
I CONFIRM I HAVE ANSWERED ALL QUESTIONS AND STATEMENTS WITH HONESTY.
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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 involved and in consideration of Eclat Clinical Esthetics' (ECLAT) willingness to conduct my spa service, I hereby release and hold harmless ECLAT, its owners, employees, agents and clients 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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