COVID-19 INTAKE FORM  

(Please print, fill and return form)

PRINT NAME: ________________________________

DATE:  _____________________________

PLEASE CIRCLE YOUR RESPONSE AND SIGN

Symptoms of COVID-19 include:

*Fever

*Chills/Shakes

*Difficulty Breathing

*Dry Cough

*Sore Throat

*Sneezing

*Skin Rashes

 

                      

1.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 *

  • Yes

  • No

 

2. 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. *

  • Yes

  • No

 

3. I understand the CDC recommends physical distancing of at least 6 feet, and this is not possible when seeking services in a day spa. *

  • Yes

  • No

 

4. I understand that The 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. *

  • Yes

  • No

 

5. I understand carriers of this virus may be asymptomatic and may still be contagious. I agree to my scheduled services given this fact and realize  that White Lotus Day Spa is sanitizing and disinfecting beyond the recommended level. *

  • Yes

  • No

 

By signing you agree to each of the above statements 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. *

 

 

Signature ___________________________________________