Covid 19 Intake Form For Central Wisconsin Clinical Massage
*This form must be filled out prior to each visit.

The purpose of this form is to add a layer of protection for everyone directly and indirectly involved with your treatment at Central Wisconsin Clinical Massage. As maintaining social distancing is not possible while working in a manual therapy setting, we need to work together to maintain not only our own health, but the health of our families, and our local communities as well.

The answers you provide on this form are crucial to helping me to provide a safe environment for all of my clients, many of whom fall into the high risk category for Covid 19 due to age or underlying physical condition.

Please know that I will be answering these questions every day as well, and will always ere on the side of caution to ensure the safest environment for you during your session.

Thank you for your understanding.
Name *
Phone *
email
Today's Date *
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Have you or any member of your household been diagnosed with Covid 19 in the past 30 days? *
Required
Have you or any member of your family been knowingly exposed to someone with Covid 19 in the past 14 days? *
Required
Have you or any member of your household attended a gathering of people where it was difficult to maintain social distancing, and masks were not worn, in the past 14 days? (Concert, graduation/birthday party, tavern, restaurant, etc) *
Required
Have you or any other member of your household had any of the following symptoms during the past 14 days? Please check any that apply. *
Required
Have you or any member or your household traveled to a different country, state, or place currently designated as a "hotspot" in the past 14 days? *
I affirm that I and all members of my household have been diligently utilizing best practices for prevention of the spread of the Covid Virus for the past 30 days including; social distancing, wearing of a mask in all indoor public places, washing hands, and avoiding crowded public events where social distancing is not being practiced. *
I understand and accept that I will be required to wear a snug fitting mask that covers my mouth and nose at all times, during the entirety of my session. *
By checking the box, I affirm that I have answered all questions accurately and honestly. I also agree to release Tom Charron LMT and Central Wisconsin Clinical Massage from liability due to the possible inadvertent exposure to Covid 19, and any harm the virus may cause. *
Required
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