Basic Kneads Massage COVID-19 Release Form
This form is provided for long term, ongoing clients. Please note that this form will be accepted as a blanket health screening for ongoing treatment, but should your treatment schedule lapse for 30 days, a new form will need to be completed. Please also note that I reserve the right to ask you to complete additional forms as treatment progresses as I feel is necessary.

**PLEASE READ EVERYTHING CAREFULLY**
Email address *
First and Last Name *
Please read carefully and check each box below. *
Required
By typing my initials below I acknowledge that I understand my name and contact information might be shared with the state health department in the event that a client or practitioner at the studio tests positive for Covid-19. *
By typing my initials below I acknowledge and understand that if I develop any symptoms of Covid-19, or test positive for the virus within 14 days of my appointment at Basic Kneads Massage, that I am being asked to immediately report it by calling Jennifer at 906-420-0990. *
To proceed with receiving care, I confirm and understand the following. Check all boxes provided. *
Required
Today's date *
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A copy of your responses will be emailed to the address you provided.
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