Health Questionnaire | Alexandra's Muse

Health Declaration

Checklist for Clients

Purpose: Based on the US Center for Disease Control Guidelines, service providers, daily, are encouraged to screen all clients for signs of respiratory illness accompanied by fever.

Instructions: All clients entering Alexandra'’s Muse Spa building must be asked the following questions below. Alexandra's Muse will maintain this record for 14 days from completion of this form and have this form available upon request from the Public Health Department.

For massage and facial services clients are required to show proof of vaccination upon arrival, these services require removal of face coverings. For services that do not require a mask removal you must wear a mask while visiting the spa.

First Name

Last Name

By checking this box, I pledge to provide only correct and truthful information when completing this screening

Have you experiencing any flu symptoms? Have you had a temperature 100.4*F / 37.8 *C or greater within the last 14 days? (Feverish or Chills)

Yes

Have you been with persons or in a facility with confirmed COVID-19 by lab test within the last 14 days?

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting the form! If you answered NO to all questions you will be allowed entry to the building. By signing the form ABOVE, I acknowledge the potential risk of contracting the COVID-19 disease during services provided today and voluntarily agreed to accept services. As a result of this release, you further agree, Alexandra's Muse Spa and its employees from any and all liability associated with your potential risk to contract NOVEL CORONAVIRUS (COVID-19).