Client Health Screening
Please complete this form 24 hours prior to your appointment
Date of Service
Time of Service
Phone and/or cell number
Do you have any of the following symptoms?
Temperature above 99.9
Shortness of breath
Loss of sense of smell and taste
Rash on skin or discoloration of fingers and toes
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?
at risk due to underlying medical conditions (e.g. heart disease, hypertension, diabetes, chronic respiratory diseases, cancer)
at risk due to a compromised immune system from a medical condition or treatment (e.g. chemotherapy
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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