Name *

First Name

Last Name

Have you had any of the following symptoms associated with Covid-19 or any flu virus in the last 24 hours? *

Fever above 99.9

Persistent cough

Sore throat

Persistent headache

Extreme fatigue

Body aches

Loss of sense of taste or smell

None of the above

Has anyone in your immediate household or place of employment received medical attention for any of the above in the last 14 days?

Yes

No

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

Yes

No

Have you received the results of your test? *

Yes, Negative.

Yes, Positive.

No. I have not received my test results.

None of the above.

Have you traveled to a country/state/ area highly affected by Covid-19 in the last 14 days? *

Yes

No

Do you have any chronic respiratory issues or autoimmune diseases? *

Yes

No

Do you suffer from seasonal allergies? *

Yes

No

The State of North Carolina strongly recommends that masks be worn when the 6-foot rule of social distancing cannot be maintained. While it is understood that certain medical conditions contraindicate wearing facial coverings, compliance with this recommendation is most appreciated. *

I agree

I disagree

I understand that precautionary measures (hand-washing, wearing a mask, and practicing social distance) aim to reduce the likelihood of infection, but carry no absolute guarantees. I understand that if I present any Covid-19 symptoms in the next 14 days, I will contact Skin Joy, LLC. I also understand that untruthful answering of questions and/or refusal to wear a mask COULD result in my name being provided IF a Covid-19 breakout were to occur and if there is a trace-back to Skin Joy, LLC or Serenity Spa & Wellness. By signing this form, I absolve Skin Joy, LLC and Serenity Spa & Wellness of any and all liability. *

I agree

I disagree

Date *

MM

DD

YYYY