Covid 19 Intake Form
To best protect your health and the health of others, please fill out this form
before each massage and bodywork session. Thank you!
Full Name *
Your answer
Today's Date *
Have you been tested for Covid19 *
When was your test taken?
Your answer
What were the results?
Your answer
Have you been in places with a high risk infection rate within the last 2 weeks? (eg. states that are considered "hotspots") *
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic. *
Do you have any new discomfort with exertion or exercise?
I declare that the above information is true and accurate to the best of my knowledge *
I understand that there is no cure or vaccine for Covid 19 and that every extra precaution that is taken to clean all surfaces and protection from respiratory droplets (ie. masks) will not guarantee that I will not be exposed to Covid19 from your massage or my office. *
I agree to let my Massage Therapist know if I have been exposed to someone who has tested positive to covid19 or I have tested positive to Covid19 immediately. *
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