Pre-Massage Screening Form

Pre-Massage Screening Form

Please complete at least 3 hours before every visit
Date of Visit*

DayMonthYear
Date
Full Name (no initials)*

First NameLast Name
Date of Birth*

DayMonthYear
Date
FeverExcessive tirednessDry cough or sore throatShortness of breathRunny noseLoss of smell/tasteUnexplained muscle or joint painVomiting/diarrheaHeadacheLoss of appetiteNone
YesNo
YesNo
Please contact me before your appointment if you answered Yes to any question. You may be asked to postpone your appointment.
Declaration

The information I have given is true, correct and complete.

I understand that massage involves touch and close physical proximity over an extended period of time, and that there is an inherent risk of transmission of infectious illness. I have been informed of this risk and consent to receive massage therapy.

For security purposes, submission details including IP address are recorded.
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty: