Coronavirus

ECLAT COVID19 Wellness Form

ATTENTION! DO NOT COMPLETE THIS FORM UNLESS YOUR APPOINTMENT IS IN THE NEXT 24 HOURS. (Updated 05/14/21)
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. Please wear a mask into the spa if you have not been vaccinated.
Name *
When is your APPOINTMENT date? (STOP IF YOUR APPOINTMENT IS NOT SCHEDULED FOR TOMORROW) *

Month Day Year
Date
Have you tested positive for COVID or been exposed to a someone with a confirmed case of Coronavirus? in the last 2 weeks? *

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

Yes 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
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 *

I will wear a face mask if I have not been vaccinated. My temperature will be taken with a no-contact thermometer and I will be asked to reschedule if I have a reading of 100.4 or above. I will wear a camisole (women) or tank top (men). I'm aware spa wraps and blankets are temporarily suspended during treatment and will bring a cover up if I feel I need to keep warm during the service. 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 involved and in consideration of ÉCLAT Skin Confidence Spa (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. *

Clear
Should be Empty:

ECLAT COVID19 Wellness Form