Name *

First Name

Last Name

Phone *

(###)

###

####

Have you been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks? *

Yes

No

Have you shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks? *

Yes

No

Have you travelled outside of your immediate daily routine in the past two weeks? *

Yes

No

Have you travelled outside of Canada in the last two weeks? *

Yes

No

Do you have a cough, fever, chills, shortness of breath, sore throat, or loss of taste or smell? *

Yes

No

If you begin to show symptoms of COVID-19 in the next two weeks, will you contact LifeStiles Spa? *

Yes

No

Will you follow all spa rules to keep yourself, your service provider, and those around you safe? *

Yes

No