COVID Form

Your Name (required)*
Your Email (required)*
By checking the boxes on the following statements, I agree that: *
- I have not had a fever in the past 24 hours of 100 degrees F or above.
- I have not had any respiratory or flu symptoms, including any of the following symptoms of COVID-19 in the past 14 days:
Fever | Fatigue Dry cough | Difficulty breathing | Chills Nausea or vomiting |Diarrhea | Confusion
I agree that: *
- I have not been in contact with anyone in the past 14 days that has been diagnosed with COVID-19 or was exhibiting any of the above symptoms.
- I, as well as all household members, have not traveled outside the country or to any city outside of my area that is or has been considered a ‘hot spot’ for COVID-19 infections in the last 30 days
- I will contact Internal Beauty Med Spa as soon as possible if I begin exhibiting any of the above symptoms within 14 days of my service.
Finally, I understand that most of the services provided by Internal Beauty Med Spa involve close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form I acknowledge that I am aware of the risks involved and give consent to receive my chosen service from my practitioner at Internal Beauty Med Spa.

By signing my name below I agree to each of the above statements and release the practitioner and Internal Beauty Med Spa from any and all liability for the unintentional exposure or harm due to COVID-19.

Your practitioner agrees that they will abide by these same standards and affirms the same. We also affirm that we have improved and expanded our sanitation and hygiene protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
Your Signature*
Date
MM slash DD slash YYYY

Get an Appointment

Complete The Form Below And We’ll Get Back To You Immediately.

*
First Last
Email Address*
Phone Number*
Select Your Service*
Write your message here...*
Phone
This field is for validation purposes and should be left unchanged.

Get an Appointment

Hear What Our Patients Are Saying.

Subscribe for News and Updates

NAVIGATION

CONTACT INFO:

ADDRESS:

OFFICE HOURS: