Spa COVID-19 Health Screening Waiver Form
Please complete this health screening and waiver before your spa visit.
Guest Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Appointment and Visit Details
Appointment Date
*
-
Month
-
Day
Year
Date
Appointment Time
*
Hour Minutes
AM
PM
AM/PM Option
Spa Service or Treatment Requested
*
Please Select
Massage
Facial
Body Treatment
Manicure
Pedicure
Waxing
Sauna
Hydrotherapy
Other
COVID-19 Health Screening
Current COVID-19 symptom status
*
No symptoms
Mild symptoms
Active symptoms
Recent exposure to a confirmed or suspected COVID-19 case
*
Yes
No
Recent positive COVID-19 test status
*
Yes
No
Waiver Acknowledgment and Signature
Signature
*
Submit
Submit
Should be Empty: