Client Health Screening
Please complete this form 24 hours prior to your appointment
Name *
Date of Service *
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DD
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Time of Service *
Time
:
Phone and/or cell number *
Do you have any of the following symptoms? *
Required
Have you or anyone living in your household been- to your knowledge- exposed to Covid 19 *
Are you considered to be a member of the vulnerable population? *
Do you have any special requests or other information to share before coming in for a massage treatment?
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. This includes but not limited to my exposure or positive test results of Covid 19 or any other related virus, upper respiratory infections or influenza. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. (By checking the agree box below I give my consent to the above mentioned) *
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