Haven COVID-19 Screening

This questionnaire is intended for internal use only. All information is strictly confidential and will not be disclosed or shared.
Are you answering for yourself or someone else? *
Have you been in close contact with another person who has been diagnosed with or under investigation for COVID-19 in the last 14 days? *
Have you traveled outside of New York in the last 14 days? *
Have you experienced the following symptoms in the last 14 days? *
Do you consider yourself at a higher risk for serious illness from COVID-19? (e.g. lung, heart, liver, or kidney disease, diabetes, immune deficiencies, pregnancy) *
Massage, facials, body treatments, waxing and nail and foot treatments may be dangerous under certain conditions. In consideration of the fee charged and paid by me and to the fullest extent permitted by the law, I hereby release Haven Spa, its employees, contractors and subcontractors and agree to hold it and them harmless from any and all liability, claims, damages, actions and causes of action whatsoever, for loss, damage or injury to person or property, irrespective of how arising and however caused. This includes but not limited to all kinds and degrees or extent of negligence (except willful or wanton negligence or misconduct) which Haven Spa may commit or be charged with in connection, directly or indirectly with the use of spa equipment and facilities and related activities.
 
If you have heart disease, hypertension (high blood pressure); if you are pregnant; if you have been advised by your physician to limit your physical activities in any way; or, if you have any medical conditions, allergy, injury or illness which may be affected by use of the spa facility or services, you must notify a receptionist, attendant or therapist priot to engaging in any spa service.
 
By signing this document, you are certifying that such disclosure has been made and agreeing to release of liability.
Signature *
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