VISITOR AND STAFF HEALTH SCREENING CHECKLIST
If you answer yes to any of the screening questions, or have a fever you will be advised to cancel appointment, stay home, and contact your health care provider. You will not be charged a cancellation fee.
Please enter your first and last name here:
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First Name
Last Name
Please enter your email address here:
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example@example.com
Please enter your Phone Number here:
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Area Code
Phone Number
Choices:
Every individual must make a personal decision about the level of risk they are comfortable with. Although I will adhere to the above guidelines, including social distancing, cleaning, reducing contact points, ect. I also understand that simply being around others may not be right or feel right for you at this time. Please only schedule a massage when the time feels safe and right for you. You inherently take on a certain level of risk when venturing into public places; it is implied that you understand these risks when coming to Spa Schwa for a session and agree to take responsibility for that risk. I will require that you and I both wear a mask during our time together. If you do not have one, I will provide one for you.
Have you had any of the following symptoms that you cannot contribute to another health condition?
Please check the box next each question if it applies to you.
Please check any box if it applies to you.
Have not had a fever or feeling feverish.
Do not have the Chills.
Do not have a new sore throat.
No new muscle aches.
No new loss of smell or taste.
I have been to a gathering of more than 10 people in the past 14 days
I have been practicing social distancing of 6 feet and wearing a mask in public places.
Someone in my immediate circle has been exposed/diagnosed with Covid-19 or sick in the past 14 days.
If you checked the box stating that you have been to a gathering of more then 10, please take a moment and explain the event and how you practice social distancing during those times.
Type your response here
Your signature indicates that you have answered the above questions truthfully. You also agree to the risk of unintentional exposure.
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Please verify that you are human
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