COVID-19 Form

Please fill out this Covid-19 form and submit before your appointment.

Have you or any persons in your household experienced any of the following symptoms in the last 14 days-including but limited to fever, dry cough, fatigue, shortness of breath, difficulty breathing, loss of taste or smell?

Yes

Have you been in contact with anyone who has exhibited any of the above symptoms in the last 14 days?

Yes

Have you or anyone you've been in contact with received a positive COVID-19 test in the last 14 days?

Yes

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures that this business has always adhered to, new preventative measures have been put in place to future reduce the spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being infected.

I acknowledge

Consent for Treatment

By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time. I voluntarily agree to assume those risks and I release and hold harmless the practitioner and The Spa at the Herrington from any claims related. I give my consent to receive treatment. *

I consent

First Name *

Last Name *

Telephone *

Date of Appointment *