Pre-Massage Screening Form

Pre-Massage Screening Form

To be completed 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.)*

FeverExcessive tirednessDry cough or sore throatShortness of breathRunny noseLoss of smell/tasteUnexplained muscle or joint painVomiting/diarrheaHeadacheLoss of appetiteNone
Have you or any of your household members experienced any cold or flu-like symptoms in the last 14 days? (including any listed above)*

YesNo
Are you or any of your household members awaiting results of a COVID-19 test or been confirmed positive for COVID-19 in the last 14 days?*

YesNo
Have you or any of your household members travelled on any cruise ships or international airlines in the last 14 days?*

YesNo
Please call ahead if you answered Yes to any question. You may be asked to postpone your appointment, or submit a rapid antigen test (RAT) on the day.
Declaration

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

I understand that because massage involves touch and close physical proximity over an extended period of time there may be an elevated risk of disease transmission, including COVID-19.

I also understand that even if an individual has received a vaccination against COVID-19 that they may still contract and transmit the virus to other individuals. The therapist has explained the risks to me and I consent to receive massage.

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

Clear
Date*

DayMonthYear
Date
Should be Empty: