Patient COVID-19 Screening

Health & Harmony Massage & Wellness Center
Date *

Month Day Year
Date
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Per CDC, ICHD, and MIOSHA guidelines, we are beginning our transition to post-Covid normalcy. If you are fully vaccinated (it has been at least two weeks since you received the final dose of an approved Covid-19 vaccine), you may present your CDC Covid-19 Vaccination Record Card to a member of our Front Desk team. Your account will be notated, and you will be exempt from having to complete this screening form in the future. Currently, we are still requiring masks, but we anticipate allowing fully vaccinated guests remove them in the near future. We do not require anyone to be vaccinated, answer questions about vaccination and/or show proof of vaccination; it is voluntary. However, unless proof is shown of vaccination (in the form of your CDC Vaccination Card), we will assume that you are not.
Have you received a Covid-19 vaccine? Please note, even if you are fully vaccinated, masks ARE still required at this time. *

Yes, I have received my first dose. Yes, I am fully vaccinated (I received my final dose more than two weeks ago). No, I have not been vaccinated. I prefer not to answer.
COVID-19 OFFICE PROCEDURES (REVISED) FOR PATIENTS:

Please read and agree to the following office procedures:
- I will fill out this screening questionnaire prior to every visit (even if visits are in the same week) unless proof of vaccination has been presented to the Front Desk.
- I understand that I must wear a mask at all times while in Health & Harmony's office. I will wear my own clean, fitted mask (no scarfs, bandannas, or neck gaiters) or one provided by Health & Harmony.
- I will keep my mouth AND NOSE covered with my mask at all times, including during my massage.
- I will sanitize my hands in the massage room prior to getting on the massage table.
- I will follow the CDC recommendations of good hand hygiene, covering my coughs and sneezes, and will not come in for a massage if I am sick.
- Our lobby is now open; you may walk right in. No need to call, ring the doorbell or wait in your car for your appointment.
- Your (fully vaccinated) Licensed Massage Therapist will choose if he or she wears a mask; however your therapist will be happy to don a mask upon your request.
I agree to abide by all of the policies listed above.

I agree I do not agree
PLEASE ANSWER THE FOLLOWING SCREENING QUESTIONS:
Have you, or ANY member of your household, experienced any of the following COVID-19 symptoms (that are new, different and/or not "normal" for you) in the past 14 days: *

Fever Dry cough Shortness of breath and/or difficulty breathing Fatigue Chills Nausea or vomiting Diarrhea Confusion Widespread muscle pain Headaches Loss of taste and smell Bruising, redness, swelling, or cramping in lower legs and feet Red or purple toes None of the above
Have you or ANY member of your household been ordered to self-quarantine in the past 14 days: *

No. Neither myself and anyone in my household have been ordered self-quarantine in the past 14 days. Yes. I or a member of my household HAVE been ordered self-quarantine in the past 14 days.
Have you or ANY member of your household had a POSITIVE COVID-19 test in the past 14 days: *

No. Neither myself and anyone in my household have tested positive for COVID-19 in the past 14 days. Yes. I or a member of my household HAVE tested positive for COVID-19 in the past 14 days.
Are you currently waiting for COVID-19 test results? *

Yes, I have tested recently due to potential exposure and not received my results. Yes, I have tested recently, but NOT due to potential exposure (i.e. routine work testing, travel prep, etc.) and have not yet received my results. No, I have tested within the past 14 days and received a negative result. No, I have not tested recently.
I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner:

I agree I do not agree
I understand that my name and contact information will be shared with the state health department in the event that a client or staff member at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department:

I agree I do not agree
My signature below is my agreement to abide by all of the safety policies listed above, as well as my affirmation that I have answered all questions honestly. My signature also signifies that I release Health & Harmony, as well as my massage therapist, from any and all liability for the unintentional exposure or harm due to COVID-19 and that I am comfortable that reasonable precaution has been taken; I accept the responsibility that staying completely out of public spaces is the most reliable way to limit my exposure to COVID-19. All representatives of Health & Harmony agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
Signature *

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Health & Harmony Massage & Wellness Center

912 Coolidge Rd, East Lansing, MI 48823

517-492-7535
Should be Empty:

Health & Harmony Massage & Wellness Center

PLEASE ANSWER THE FOLLOWING SCREENING QUESTIONS: