COVID-19 Form
This form is required for all appointments starting June 29th, 2020. This form contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and honestly so we can protect you and our community to the best of our ability.
Email *
Full Name *
Have you been in contact with someone with a confirmed case of COVID-19 in the last 14 days? *
Have you had a fever of 100 degrees or higher in the last 24 hours? *
Have you had a new loss of sense of taste or smell? *
In the last 14 days have you experienced any flu like symptoms? (fever, cough, shortness of breath, sore throat, runny nose, nausea, vomiting or diarrhea) *
Have you had laboratory exposure while working directly with specimens known to contain COVID-19? *
Have you had any new onset of muscle aches, fatigue, and/or pain since the emergence of the virus? *
Have you noticed any new marks, rashes, spots, bumps, or other lesions on your skin? *
Are you able to exercise to get your heart and respiratory rate up without any problems? *
Have you ever had a stroke, TIA, or blood clots or at risk for such? *
By typing my initials below I acknowledge that I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this 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 Sandstone Therapeutic Massage, that I am to immediately report it to Sandstone by calling (248)-348-8770 and email *
To proceed with receiving care, i confirm and understand the following. Check all boxes provided) *
By signing my name below I give full consent to continue treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. *
Today's Date *
A copy of your responses will be emailed to the address you provided.
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