Privacy of personal information is an important principle to Essentials South Tampa Day Spa. We are commited too collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. 

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PLEASE READ / INITIAL THAT YOU UNDERSTAND THE FOLLOWING:

 

My temperature has not been above 98.6 f in the past 72 hours.


                               

I have not knowingly been in contact with anyone diagnosed with COVID-19 in the past 2 weeks.


                                                                             

I have not had any of the following symptoms in the past 2 weeks;Fever, Cough, Shortness of Breath, Persistent Chest Pain or Pressure.  


             

I acknowledge I am receiving Massage Therapy/ Facial Treatments knowing that social distancing cannot be adhered to during my Massage/Facial session.      


                                                                                                         

In the event I contract COVID-19, I will notify my Massage Therapist/Facial specialist as soon as possible.                                                 


 

COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person to person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. Your Massage Therapist/ Facial Specialist has put in place preventive measures to reduce the spread of Covid-19; However, your Massage Therapist/ Facial Specialist cannot guarantee that you will not become infected with COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving Massage Therapy/ Facial Services and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all the forgoing risk and accept soul responsibility for any injury to myself (Including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense of any kind, that I may experience or incur in connection with my Massage Therapy/Facial appointment. On my behalf I hereby release,  covenant not to sue, discharge, and hold harmless my Massage Therapist/ Facial Specialist, or Essentials South Tampa establishment, and any interested parties from the claims, including all liabilities, claims, actions, damage, cost or expense of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of my Massage Therapist/ Facial Specialist, or Essentials South Tampa where my massage therapy/ Facial services are received, whether a COVID-19 infection occurs before, during, or after any participation in a massage therapy or facial service. 

I Agree

 

                                                           January 22, 2021                          

First Clients Name

First Name*

Last Name*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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