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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 100.4°F/ 38°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I am not experienceing shortness of breathe or difficulty breathing or any of the following:

Fatigue

Muscle or body aches

Diarrhea

Nausea or Vomiting

Congestion or runny nose

Sore throat

Headache

I understand that if at any time during the appointment, I develope any of the above symptoms, I will immediately notify my consultant and remove myself from the spa environment.

Are you experiencing any of the previous symptoms?

No

Yes

Have you tested positive for COVID-19 in the last 14 days?

No

Yes

Have you been or exposed to anyone testing positive for COVID-19 in the past 14 days?

No

Yes

I declare that the information that I have provided is accurate & complete.

Initials

Date

Thanks for submitting!

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