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!
Have you been tested for Covid19
When was your test taken?
What were the results?
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.
Diarrhea, digestive upset
Nasal, sinus congestion
Loss of sense of taste or smell
Shortness of breath
Sudden onset of muscle soreness (not related to any specific activity)
Rash or skin lesions (especially on the feet)
I have NOT experienced any symptoms
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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