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.
Sign in to Google to save your progress. Learn more
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.  I will inform the studio ahead of time should I wish the Therapists to wear a mask during the session. *
Today's Date *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Sandstone Therapeutic Massage LLC. Report Abuse