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COVID-19 QUESTIONNAIRE

The novel Coronavirus (Covid-19), has been declared a worldwide pandemic by the WHO. Covid-19 is extremely contagious and is believed to spread mainly from person to person contact.

Skin to Soul Wellness located at 155 Rochdale Dr. South Suite E Rochester Hills, MI 48309 has put in to place reasonable preventative measures to reduce the spread of Covid-19. These measures include increasing sanitation and disinfection procedures, staggering appointment times, requiring client participation in sanitation protocols, and solicitation of a health history review from each client prior to each appointment. However, given the nature of this virus, there is still an inherent risk of becoming infected with Covid-19 by virtue of simply being at the premises and engaging in elective services that violate official recommendations for social distancing.

With your completion of this Health Screening Review, Advised Consent and Liability Release Waiver, you understand, acknowledge and consent to the risk you are assuming in engaging in business with Skin to Soul Wellness in the midst of the Covid-19 pandemic. You affirm that Skin to Soul Wellness is taking all the steps necessary to preserve your safety within the premises and acknowledge the impossibility of Skin to Soul Wellness fully eliminating your potential exposure to the Covid-19 contagion. You thereby understand the risk you are assuming as a client to being treated in the midst of the Covid-19 pandemic and agree to release Skin to Soul Wellness and all its staff members from any all liability for any unintentional exposure or harm due to Covid-19

.Important Notes: Clients who make appointments for services who do not complete this waiver prior to arriving for their scheduled appointment and/or refuse to comply with spa mandated virus prevention such as wearing a mask, will not be seen/treated and will have financial penalties associated with a no call/no show applied to the requisite payment on file. Additionally, it is more imperative than ever that clients are timely to appointment times to fulfill staggered scheduling for the purposes of social distancing. Skin to Soul Wellness requests that if you've had any sort of cold or flu in the last 2 weeks that you reschedule your appointment after you've been symptom free for 14 days. All prior cancellation and rescheduling policies remain in place.

Symptoms of Covid-19 include:

  • Fever
  • Chills/Shakes
  • Difficulty Breathing
  • Sore throat
  • Dry cough
  • Skin Rashes
  • Nausea/Vomiting
  • Sudden loss of taste or smell 

 

I understand that the above symptoms and affirm that I, as well as my household members, DO NOT currently have nor have experienced the symptoms listed above within the last 14 days.

I Agree

I affirm that I, as well as household members, have not been diagnosed with Covid-19 within the last 14 days.

I Agree

I affirm that I, as well as household members, have NOT knowingly been exposed with anyone diagnosed with Covid-19 or to anyone who has displayed flu like symptoms within the last 14 days 

I Agree

I have not travelled out of the State of Michigan within the past 14 days

I Agree

I agree to have my temperature checked upon arrival 

I Agree

Today's Date: December 2, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

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Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

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Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

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

Email*

Confirm Email*
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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*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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