| The Green Spa & Wellness Center

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8804 Third Avenue Bay Ridge
Brooklyn, NY 11209

(718) 921-6100
info@greenspany.com

Mon - Closed
Tues 12pm - 5pm
Wed 12pm - 8pm
Thurs, & Fri 10am - 6pm
Sat 9am - 5pm
Sun - Closed

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Covid Screening

Welcome! We want to make your stay as pleasant and as comfortable as possible. If you have any questions regarding your therapy session, please let us know.

This document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions.
Name*
First Last
Phone*
Have you been vaccinated? Have you been vaccinated? If yes, skip to the consent section on the bottom.*
- Yes (skip to submit button)
- No
Have you recently experienced any of the following COVID-19 related symptoms: (If Yes, please explain)
fever
chills
muscle aches
loss of taste or smell
respiratory or flu symptoms
shortness of breath
coughing
sore throat
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*
- Yes
- No
Have you had a fever in the last 24 hours of 100°F or above?
- Yes
- No
Have you or anyone in your household been tested for COVID-19?
- Yes
- No
Have you or anyone in your household traveled outside the U.S. in the past 14 days?
- Yes
- No
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 14 days?
- Yes
- No
Have you or anyone in your household traveled outside the New York State in the past 14 days?
- Yes
- No
Consent for Treatment
To proceed with receiving care, I confirm and understand the following (CHECK BOX in all places provided)
I am aware I need to wear a mask to enter the facility, in all common areas and during most treatments.
- YES
I am aware if I do not have a mask there will be a disposable masks available for me at the front desk.
- YES
I consent to have my temperature taken and recorded upon entering the facility
- YES
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.
- YES
I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.
- YES
By typing your name below this acts as signature:
First Last
Consent
I agree to the privacy policy.
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8804 Third Avenue Bay Ridge, Brooklyn, NY
(718) 921-6100

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