ESSpa Covid-19 Services Consent Form
By submitting this form, you acknowledge the truthful answers to the questions below in order to have hair, skin, nail or body services during the State-designated crisis/pandemic.
Please enter a valid phone number.
Have you received a Covid19 Vaccination?
I'm Scheduled to get it.
By checking the boxes, you confirm that the following statements are true:
I agree to follow all ESSpa rules and protocols (written and/or verbal) during my visit/appointment in order to minimize the spread of viruses.
I have NOT been diagnosed with COVID-19 last 14 days.
I am NOT currently waiting for results for a personal COVID-19 test.
I have NOT traveled outside of Western PA in the last 14 days.
I do NOT live with or see on a frequent basis anyone who has had a positive Covid-19 test result in the past 30 days.
I do NOT live with or see on a frequent basis anyone who has taken a Covid-19 test and is currently waiting for results.
I have NOT attended any gathering of 10+ people in the past 14 days.
I agree to properly wear a face covering while inside ESSpa.
I understand the risk of unintentional exposure to virus while visiting ESSpa.
If I do NOT answer truthfully to any of the questions above I understand that I may be subject to civil penalty and prosecution as allowed by law.
Do you have any of these symptoms? (check all that apply):
Fever (above 100.1)
Loss of Taste and/or Smell.
Shortness of Breath..
Unusual or extreme tiredness.
I DO NOT HAVE ANY Covid-19 Symptoms.
Have you been in contact with anyone that has COVID-19 symptoms or was/is infected in the last 10 days?
Do you have any issue(s) - medical or otherwise - that we should be aware of that might impact your visit to ESSpa?
If "Yes" above please explain
Have you traveled anywhere beyond Western Pennsylvania in the past 10 days?
If "Yes" above please tell us where you traveled and when you returned.
Please Check Box and then Sign Below:
I agree not to enter ESSpa (spa or salon) for any reason if I am sick or have the symptoms of COVID-19. I Understand that any services I receive at ESSpa are provided for the basic purposes of relaxation and that ESSpa Service(s) should not be inferred and/or construed as a substitute for medical examination, diagnosis, or treatment and nothing said in the course of my appointment should be considered as such. I agree that I have clearly provided all my known medical conditions and answered all questions honestly and I agree to inform my ESSpa Service Provider of any changes in my medical status. By signing below, I confirm that all the personal statements in this form are true and valid and willingly provided by me without coercion. I agree to pay in full for any and all appointment(s) scheduled by/for me on the date of service. If I do not show for a scheduled appointment(s) without giving 24 hours notice, I agree to still pay for the service(s). I will abide by all ESSpa rules and protocols (posted or otherwise) and I hereby indemnify and release ESSpa, its owners and employees from any and all liability from unintentional exposure or harm due to Covid19. I understand that if it is determined that I have not answered truthfully any of the questions on this form, I agree that I may be subject to civil prosecution and/or penalties as may be allowed by law.
Parent/Guardian Name (if applicable)
Should be Empty: