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913-441-9090
clients@lavitabelladayspa.com

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Home
About
- About Us
- Staff
Services
Specials
Products
Your Visit
Forms
Careers
Social
Contact

913-441-9090
clients@lavitabelladayspa.com

Covid-19 Health Screening Form

Covid-19 Health Screening Form

Home › Your Visit › Covid-19 Health Screening Form

Covid-19 Health Screening Form

Full Name:*

Address:*

Email:*

Phone Number:

My temperature has not exceeded 100.4 degrees in the last 14 days. :*

Agree Disagree

I have not experienced any coughing or respiratory issues in the last 14 days.:*

Agree Disagree

I have not experienced any unexplained shortness of breath or difficulties in the last 14 days.:*

Agree Disagree

I have not been in close contact with anyone that has been diagnosed with Covid-19 or any similar flu-like illnesses.:*

Agree Disagree

I have not traveled to or from any affected geographic regions within the last 30 days.:*

Agree Disagree

I will notify La Vita Bella Day Spa if I start to exhibit any of the above symptoms in the next 14 days.:*

Agree Disagree

I understand that upon entry to La Vita Bella Day Spa I may be asked to leave if I exhibit any symptoms listed above.:*

Agree Disagree

Choose One:*

I have filled this form out for myself. I have filled this form out to the best of my knowledge for my significant other, adult child or parent, over the age of 18 I have filled this form out for my minor child, and I give La Vita Bella Day Spa LLC permission to perform the services scheduled, while holding La Vita Bella Day Spa LLC and its staff harmless to any adverse reactions.

Name of person:*

Name of minor:*

Signature:*

Date:*

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La Vita Bella Day Spa
5416 Roberts Street
Shawnee, KS
clients@lavitabelladayspa.com
913-441-9090

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