Lili’s Esthetics Studio
Name: ________________________________________
I understand the novel coronavirus causes the disease known as COVID19. I understand the novel coronavirus has a long incubation period
during which carriers of the virus may not show symptoms and still be
contagious. _____ (Initial)
I understand that due to the frequency of visits of other spa clients,
that I have an elevated risk of contracting the novel coronavirus simply
by being in the spa environment. _____ (Initial)
I confirm that I am not presenting any of the following symptoms of
COVID-19 identified by Ontario Health Services:
 Fever >38℃ _____
(Initial)
 Sore Throat _____
(Initial)

_____
 Difficulty
(Initial)
Breathing
 Runny Nose _____
(Initial)
 Cough
 Shortness of
Breath

 Flu-like
symptoms
_____
(Initial)
_____
(Initial)
_____
(Initial)
I confirm that I am not in a high-risk category, including diabetes,
cardiovascular disease, hypertension, lung diseases (including
moderate to severe asthma), being immunocompromised, having
active malignancy, over the age of 65. _____ (Initial)
o I understand the above symptoms and affirm that I, and all
household members, do not currently have, nor have experienced
the symptoms listed above within the last 14 days.
o I affirm that I, and all household members, have not been
diagnosed with COVID 19 within the last 30 days.
o I affirm that I, and all household members, have not knowingly
been exposed to anyone diagnosed with Covid-19 within the last
30 days.
o I affirm that I, and all household members, have not travelled
outside of the country, or to any city considered a “hot spot” for
Covid-19 infections within the last 30 days.
o I understand that this business, and its estheticians, can not be
held liable for any exposure to the virus or any other contagion
caused by misinformation on this form or the health history
provided by each client.
_________________________________________
CLIENT SIGNATURE
_________ /________ / 2020
MONTH
DAY