Covid-19 Client Screening Form

COVID 19 Form

Purpose: 

Based on the US Centers for Disease Control Guidelines, service providers are encouraged to screen all clients daily for signs of respiratory illness accompanied by fever. 

Instructions:

All clients entering the Put Your Woman First Yoni & Spa building must be asked the following questions. PYWF will maintain this record for 14 days from the completion of this form and make it available upon request from the Public Health Department.

Do you have any of the following respiratory symptoms? 

  • If YES to any, please call and cancel your appointment immediately.
  • If NO to all, proceed to the remaining statements. 

If you answered NO to all questions, you will be allowed entry to the building. However, please be aware of the following protocols:

  • You will immediately wash your hands for at least 20 seconds upon entry into the building 
  • Not to shake hands with, touch, or hug others during your time in the building 
  • Not congregate in any space within the Yoni area and spa. 
  • By signing the form below, I acknowledge the potential risk of contracting the COVID-19 disease during services provided today and voluntarily agree to accept services. You further agree and hereby release PYWF Yoni and Spa and its employees from any and all liability associated with your potential risk of contracting NOVEL CORONAVIRUS (COVID-19). 

If needed, the person answering YES to any of the above questions is responsible for following up with their primary care physician.