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.
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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 14 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
I have received one or both vaccine doses. *
I have been tested and received a positive diagnosis of Covid. (No self diagnosis) *
Please provide the date of your Covid diagnosis
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I affirm that all members of my immediate family have been carefully adhering to all basic recommended protocols to prevent the community spread of Covid 19 including: the wearing of masks in all public places, social distancing, avoiding large groups of people where mask wearing is not universal, and washing hands frequently. *
Due to the highly contagious Delta variant (which is now in the area), I understand that I am required to wear a snug fitting mask which covers my mouth and nose at all times throughout the duration of the treatment session. *
By checking the box below, I affirm that I have answered all of the above questions accurately and agree not to hold Tom Charron LMT or Central Wisconsin Clinical Massage liable should I inadvertently contract Covid 19 during a treatment session.
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