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
COVID-19 OFFICE POLICIES & PROCEDURES

Due to the 2019-2020 COVID-19 pandemic, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. We continue to closely monitor the progression of COVID-19 and are staying abreast of the latest information available from a number of trusted healthcare sources, including the CDC and ICHD. We must be vigilant in upholding all additional precautions at this time, as just one case of exposure in the office could cause us to shut down again. We need 100% compliance with all of our policies and procedures, no exceptions.

HEALTH & HARMONY OFFICE PRACTICES:
- Every massage therapist washes their hands with soap and hot water up to their elbows, and scrubs under the fingernails, before and after every massage as well as after handling dirty linens or other massage equipment and/or cleaning.
- Massage tables, face cradles, as well as all hard surfaces (light switches, side tables, clothes bins, doorknobs, etc.) in the massage room are cleaned with 70% alcohol after every patient.
- Hard surfaces around the office, such as doorknobs, countertops, side tables, bathroom fixtures, etc. are cleaned frequently with 70% alcohol.
- All linens are laundered with All Free & Clear, Oxiclean or Dawn Dish Washing Liquid (to strip away oil residue in the sheets) and are washed and dried on high-temperature cycles.
- Your massage therapist will wear a face mask at all times and will don a fresh apron for each appointment.
- We will turn away any patient who's screening questionnaire turns up a risk factor and/or appears to be infected with a viral illness. We will not work on patients who are ill.
- All staff will be screened daily for temperature and COVID-19 symptoms. All staff will stay home if not feeling well and/or will be sent home if they do not pass the daily screening.
NEW OFFICE PROCEDURES FOR PATIENTS:

Rest assured, we will not sacrifice the health and safety of our patients or staff. We don't like this new way of operating either, but if we want to stay open, we must be absolutely stringent in protecting your safety and ours. We need your participation too, as we are all in this together. Please read and agree to the following new procedures for patients:
- I will fill out this screening questionnaire prior to every visit (even if visits are in the same week).
- I understand that your lobby is closed until further notice. I will call or ring the video doorbell upon my arrival for my appointment and wait in my car or outside.
- I understand that a member of Health & Harmony's staff will check my temperature and that my appointment will be rescheduled for a later date if I register a temperature of 100.4 degrees or higher.
- 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 understand that if I am unable to wear a mask (for any reason) that I must wait until masks are no longer required before I can receive a massage at Health & Harmony.
- I will keep my mouth AND NOSE covered with my mask at all times, including during my massage.
- I will leave unnecessary items in my car. I will place everything (EXCEPT MY FACE MASK) that I wore and/or brought in with me in the sanitized bin provided in my massage room.
- 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.
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.
(Optional) Have you received a Covid-19 vaccine? Please note, even if you are fully vaccinated, masks are still required (staff is not vaccinated yet).

Yes, I have received my first dose. Yes, I have received my second dose. No, I have not been vaccinated.
MONITORING OF LOCAL OUTBREAKS

To continue doing our best to keep staff and clients safe from COVID-19, we are monitoring cases in the area. These questions may change to reflect the confirmed cases in the area. Currently, there are no major outbreaks in the area.
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.
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Health & Harmony Massage & Wellness Center

912 Coolidge Rd, East Lansing, MI 48823

517-492-7535
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Health & Harmony Massage & Wellness Center

PLEASE ANSWER THE FOLLOWING SCREENING QUESTIONS:

MONITORING OF LOCAL OUTBREAKS