Safety form – My Spa Rituals

Full Name

Phone Number

In the past 14 days, I have experienced...

Fever 101°F +

Yes NO

Unexplained body aches or pain

Yes No

Coughing

Yes No

Sore throat

Yes No

Shortness of breath

Yes No

Chills with or without body aches

Yes No

Unexplained sores on soles of feet

Yes No

Unusual fatigue

Yes No

Non-allergy related runny nose

Yes No

Have you been with anyone who was confirmed to have COVID 19 by lab test within the last 14 days?

Yes No

"IF YES to any of the questions above please call us immediately and cancel your appointment."
"IF No to all proceed with remaining statements."

If you answered NO to all questions you will be allowed entry to building.
Please be aware of the following protocols:

You will immediately wash your hands for at least 20 seconds upon entry into the building.

Not to shake hands with, touch or hug others during your time in the building.

Not congregate in any space within the salon & spa.

By signing the form bellow I am acknowledging the potential risk to contract the COVID 19 disease during serviecs provided today and voluntarily agreed to accept services. You further agree and hereby release My Spa Rituals & Esthetics and employees from any and all liabilities with your potential risk to contact Novel Corona virus (COVID-19).

*The person answering YES to any of the above questions is responsible for following up with their primary care physician if needed.

Signature

I Agree

I agree that I am providing accurate health information.

COVID-19 Screening Checklist