COVID-19 Screening

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- Angela Bain
- Amanda Keiler
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Lifespa Wellness Center COVID-19 Screening

* Indicates required field

Name *

First

Last

Middle *

Middle name

Date Of Birth *

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Covid 19 Symptoms: *

Fever Shortness of Breath Fatigue Cough Loss of Taste or Smell None of the Above

Have you knowingly been exposed to someone who has tested positive for the Cornona Virus within the last 14 days? *

No Yes, I need to cancel session

Covid 19 Information:
During a massage session, it is not possible to maintain social distancing. You and your therapist will be sharing a treatment room in close contact with one another for an extended period of time. Although masks are optional at this time, please note that should Covid levels rise or should regulations shift, we will ask that masks be worn during your visit. We are happy to provide a mask for you. Also if your therapist is not wearing a mask, please do not hesitate to request that they wear one. We are happy to! We ask that all visitors wash their hands or use our hand sanitizer stations upon arrival.

Choose One *

I consent and wish to proceed with my session. I do not consent and wish to cancel my session.

Signature:

Please enter your full name *

Entering your full name will act as your signature

Today's Date *

Are you under the age of 18? *

If you are under the age of 18, a legal guardian's signature is required.

Guardian's full name *

Guardian, entering your full name will act as your signature.

Guardian's relationship to minor *

i.e. Parent, Grandparent

By submitting this form you are agreeing that the information disclosed is true and correct.

Submit

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HOURS UNTIL FURTHER NOTICE ARE BY APPOINTMENT ONLY
Monday 8 AM - 5 PM | Tuesday - Thursday 9 AM - 6 PM
Friday 8AM - 5 PM | Saturday 8 AM - 2PM
Extended service hours are available Tuesday through Thursday by appointment

​​Lifespa Wellness Center COVID-19 Screening

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Lifespa Wellness Center COVID-19 Screening