Disclosure Form

Client Health Disclosure Form

This form must be completed and submitted within 24-hour before your appointment, and is only valid for 24-hours prior. This form will be required before all Sanctuary Day Spas appointments. Please consider the safety of yourself and our staff.

Name *

First

Last

Location *

Date of Appointment

Please answer all questions below

I have not experienced a new/worse cough, shortness of breath, difficulty breathing, sore throat, runny nose, headache, fever, loss of taste/ smell, rashes or redness on feet/toes in the past 14 days. *

True
False

I have not come into contact with anyone with any of the previously stated symptoms in the past 14 days. *

True
False

I have not been in contact (or anyone whom I have had contact with) someone who travelled or worked in a hospital known to be experiencing an outbreak of COVID-19 in the last 14 days. *

True
False

I have not tested positive or come in contact with someone who has tested positive of COVID-19 in the past 14 days. *

True
False

Access to this spa will not be granted to any guest who has either not completed this form, or has been unable to check all of the above criteria.

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