Name *

First Name

Last Name

Phone *

(###)

###

####

I knowingly and willingly consent to having Spiritual Solutions service(s) during the COVID-19 pandemic. *

by checking this box I understand and accept this statement.

To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow Spiritual Solutions guidelines. *

by checking this box I understand and accept this statement.

I understand that due to the frequency of visits of other clients, the characteristics of the virus, and the characteristics of psychic and spiritual services, that I have elevated the risk of contracting the virus by merely being in the shop. *

by checking this box I understand and accept this statement.

I understand that COVID-19 is extremely contagious and may be contracted from various sources. COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it, and who does not give the current limits in virus testing. *

by checking this box I understand and accept this statement.

I verify that I have not traveled outside the United States In the past 14 days. *

by checking this box I understand and accept this statement.

I confirm that I have not traveled domestically within the United States by commercial airline, bus, ship or train within the past 14 days. *

by checking this box I understand and accept this statement.

I confirm that myself and my family member hadn't any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *

by checking this box I understand and accept this statement.

I agree not to come inside the Spiritual Solutions shop with the following symptoms of COVID-19 listed below: Fever, High Body Temperature, Fatigue, Shortness of breath, Loss of sense of taste or smell, Dry cough, Runny nose, or Sore throat. *

by checking this box I understand and accept this statement.

I understand that COVID-19 health questionnaire is required before entering the shop every time. I'll allow to take temperature, if my temperature is 100 or higher, I'll go home. *

by checking this box I understand and accept this statement.

With limitation clients in the shop, I understand that I must make an appointment and outside waiting area is for customers only. I will not bring children and/or friends in the shop whom are not being serviced. *

by checking this box I understand and accept this statement.

I'll REMEMBER to bring my face masks, or I'll be refused service(s). I agree that it is mandatory to wear a face mask at all times inside if I forget to bring one, one will be provided at the shop. *

by checking this box I understand and accept this statement.

I understand, read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to ensure the safety of our community and to provide the best possible guest experience when visiting Spiritual Solutions. *

by checking this box I understand and accept this statement.