Skincare Lounge SPA                                             COVID-19 Screening Questionnaire
In following both CDC and ADA recommendations, this questionnaire is designed with your safety in mind. Your answers will be reviewed prior to your appointment and a member of our team will contact you if we recommend rescheduling to a later date. Thank you for your consideration and understanding.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits .
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Client's Name *
Client's Phone Number *
Client's Email *
Have you ever been diagnosed with COVID- 19 *
Do you have a fever AND respiratory symptoms like cough or shortness of breath? *
Have you had a close contact with a person infected with COVID-19 or history of travel to an affected geographic area in the last 21 days? *
Are you having difficulty breathing, unable to eat or drink, or too weak to care for yourself? *
Are you currently experiencing pain or swelling? *
Is there anything else our team should know before starting your skincare treatment?
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Skincare Lounge SPA has put in place strict and preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Skincare Lounge SPA cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, SPA staff, and other Skincare Lounge SPA clients and their families. I voluntarily seek services provided by Skincare Lounge SPA and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that:* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.* I have not traveled internationally within the last 21 days.* I have not traveled to a highly impacted area within the United States of America in the last 21 days.* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19…I hereby release and agree to hold Skincare Lounge SPA harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Skincare Lounge SPA, or that may otherwise arise in any way in connection with any services received from Skincare Lounge SPA. I understand that this release discharges Skincare Lounge SPA from any liability or claim that I, my heirs, or any personal representatives may have against the Skincare Lounge SPA with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Skincare Lounge SPA. This liability waiver and release extends to the Skincare Lounge SPA together with all owners, partners, and employees. *
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