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
Are you currently experiencing any cold or flu-like symptoms? (e.g. fever, cough, sore throat, runny nose, headache, shortness of breath etc.)
Have you experienced any cold or flu-like symptoms in the last 7 days? (e.g. fever, cough, sore throat, runny nose, headache, shortness of breath etc.)
Please contact me if you answered Yes, or have had recent household exposure to confirmed Covid-19 or influenza. You may need to postpone.
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
Date

DayMonthYear
Date
Should be Empty: