COVID-19 Intake Form

Personal Information
COVID-19 Symptoms
  • Fever
  • Chills/Shakes
  • Difficulty Breathing
  • Dry Couch 
  • Sore Throat
  • Sneezing
  • Skin Rashes
I understand the COVID-19 symptoms listed above and affirm that I, as well as my household members, DO NOT currently have, nor have experienced the symptoms listed above within the last 21 days:
I affirm that I, as well as all household members, have not traveled outside of the country, or to any "hot spot" for Covid-19 such as NYC in the last 30 days:
I understand that White Lotus Day Spa and your therapists cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the client intake form:
I understand the CDC recommends physical distancing of at least 6 feet, and this is not possible when seeking services in a day spa:
I understand carriers of this virus may be unsymptomatic and may still be contagious. I agree to treatment given this fact and realize White Lotus Day Spa is sanitizing beyond the recommended level:
By signing you agree to each above statement and release White Lotus Day Spa and all of its therapists from any and all liability for the unintentional exposure or harm due to Covid-19:
​By typing your full name below you are agreeing to the use of electronic records and signatures