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Health History Review and Consent Form

Due to COVID-19 we are taking extra precautions to protect your health and the health of our staff members with an intake for each client that includes an updated health history review. This intake will be performed each time you visit Firefly Wellness Day Spa, until further notice.

We require that you take your temperature at home before EACH VISIT to Firefly. If your temperature is 100.4 or higher please reschedule your appointment.

Is your temperature today 100.4 degrees or higher? *

Yes

Have you recently had any other COVID-19 symptoms? *

Yes

Please initial:

I affirm that I, as well as all household members do not currently have, nor have experienced any COVID-19 symptoms within the last 14 days. *

I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 14 days. *

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 14 days. *

I affirm that I, as well as all household members, have not traveled to, or been in, any area that is considered a 'hot spot' for COVID-19 infections within the last 14 days. *

I understand that this business and the employees cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. *

I understand that if I test positive for COVID-19 within 14 days after my visit I must notify Firefly Wellness Day Spa so that they can properly trace and notify the other exposed clients and employees as needed. I understand that if I so choose I can request that Firefly Wellness Day Spa keep my identity confidential. *

I understand that before entering Firefly Wellness Day Spa I must take my temperature and when I enter I may be required to wash/sanitize my hands and wear a mask or face covering. I also understand that I may be refused entry if I don’t not comply with the current Firefly Wellness Day Spa policies and procedures. *

By signing below I agree to each above statement and declare that the information provided is true and accurate to the best of my knowledge. I acknowledge and understand the risk of being exposed to COVID-19, and voluntarily agree to assume all risks involved when visiting Firefly Wellness Day Spa, releasing the business and its employees from any and all liability for the unintentional exposure or harm due to COVID-19.

This business and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

~ The Firefly Wellness Day Spa Team ~

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Health History Review and Consent Form

March 6, 2021