C-19 Protocols & Disclaimers
Due to the infectious nature of COVID-19, this additional intake form must be completed before each bodywork session. Please answer these questions truthfully and do everything asked so we can do our best to protect each other.
As a healthcare worker, I am committed to keeping you as safe and healthy as possible. The CO Dept of Regulatory Agencies (DORA) has issued the following protocols for Massage & Bodywork practices.
These precautions may seem awkward, and I apologize for the inconvenience, but they are meant to protect you & your loved ones.
Please know that people with COVID-19 can be asymptomatic and still be contagious. As of this writing (3/1/2021) there is no way to completely protect yourself from the virus, although the vaccine is a promising step. EVEN IF YOU HAVE BEEN VACCINATED, THESE PRECAUTIONS MUST STILL BE FOLLOWED. Take a look at the precautions I am taking on my website:
http://www.souljournerhealingarts.com/corona-health-safety
.
* Required
Email address
*
Your email
Your full name:
*
Your answer
Symptoms Check - please reschedule your session if you are experiencing any of the following
Fever
Cough
Sore Throat
Shortness of breath
Sudden lost of taste and/or smell
Fatigue
Chills
Nasal or Sinus Congestion
Sudden onset of body aches
New rash or other changes to the skin
Exposure
*
Yes
No
Are you aware of having been exposed to
Have you travelled by air in the last 2 weeks?
Have you traveled to any places with a high infection rate, where people have not been isolating (no stay at home order), or been in any groups of people where social distancing was not observed?
Yes
No
Are you aware of having been exposed to
Have you travelled by air in the last 2 weeks?
Have you traveled to any places with a high infection rate, where people have not been isolating (no stay at home order), or been in any groups of people where social distancing was not observed?
Testing status (optional): Have you been tested for COVID, and/or for antibodies in the past month? If so, when, and what were the results?
Your answer
Vaccination (optional) - if comfortable, share your vaccination status/progress (1 shot /both; amount of time since last shot).
Your answer
Next
Page 1 of 2
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
