Are you fully vaccinated? *

Yes

No

As a Guest at Blooming Moon Spa:*

I understand that Blooming Moon Spa and/or my therapist can refuse service if there is any concern for the safety and well-being relating to covid.

As a Guest at Blooming Moon Spa: *

I do not have any COVID symptoms: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea.

As a Guest at Blooming Moon Spa: *

I have not been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus symptoms.

As a Guest at Blooming Moon Spa: *

I understand that my name, appointment type, date, spa provider and any other information may be shared for COVID-19 contact tracking if asked by the CDC (Center for Disease Control and Prevention) only.

As a Guest at Blooming Moon Spa: *

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

I understand that, because receiving spa services involves maintained touch and 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 from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

Name *

First Name

Last Name

Today's Date *

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