COVID19 Check In Form

1
Full Name* This field is required.
First Name
Last Name
2
Email
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Governor Walz has asked persons of high-risk for complications related to COVID19, as well as all Minnesotans to voluntarily stay home to reduce unnecessary travel. T&SRM respects your need to reschedule, postpone, or cancel your appointment in order to stay home. Please notify T&SRM with your intent to do so within 24 hours of your scheduled appointment time to avoid any late cancelation fees. If you should become suddenly ill, please notify this office at least 1 hour before your appointment time.
5
Have you had any of the following symptoms since the last time you were here that you cannot attribute to another health condition? (Check all that apply):* This field is required.
Fever (100.4°F or higher) or feeling feverish?
Chills?
A New Cough?
Shortness of breath?
A new sore throat?
New muscle aches?
New Headache?
New lost of taste or smell?
Nausea/Vomiting?
Fatigue?
I have not experienced any of these symptoms
6
COVID19 is spread through close contact (less than 6 feet) with others infected with the SARS-CoV-2 virus, including those who may be asymptomatic (are not showing or experiencing symptoms). Close contact spread over time (greater than 15 minutes) increases the risk of transmission of the virus. Massage sessions are performed at close contact for long period of time, creating a medium risk exposure to SARS-CoV-2. Please check that you understand the following statement and give consent to receive massage.* This field is required.
“I understand that close contact with people increases the risk of infection from COVID-19. I understand that massage therapy sessions are considered medium risk to exposure to the SARS-CoV-2 virus that causes COVID19. By checking this statement on this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner and do not hold the practitioner or T&SRM responsible should I become ill.”
7
The following safety precautions will be required to receive massage at T&SRM, please check each box to acknowledge:* This field is required.
I understand my temperature will be taken at each appointment
I understand a temperature of 100°F and above will result in rescheduling
I understand that I will need to wear a mask for my entire session
I understand that I will need to sanitize my hands upon arrival and checkout
I understand I should try to keep talk to a minimum during session and at checkout
I understand I should make appointments online from home when possible
I understand that if I experience any of the above symptoms at any time I should reschedule my appointment until at least two weeks after they appear or when cleared by a medical provider
I understand that if I arrive more than 10 minutes early, I should wait in my car until the appropriate time
I understand that health checks will be completed before every massage session
8
COVID19 can take up to 14 days to show symptoms and is highly contagious. If the practitioner is exposed to SARS-CoV-2 (the virus that causes COVID19), T&SRM will be required to close for a minimum of 14 days or until cleared by a medical provider. All appointments during that time will be canceled. You may be notified of possible exposure and cancelation of your appointment on short notice. Please check that you understand the following statement and you give consent to receive massage.* This field is required.
“I understand that due to the incubation time of the SARS-CoV-2 virus, that if the practitioner is exposed to the virus, my appointment and all other client appointments will be cancelled for a minimum of 14 days”
9
The following health conditions are HIGH RISK for serious complications related to COVID19: Asthma, Chronic Kidney, Chronic Lung Disease, Diabetes, Hemoglobin Disorders, Immunocompromised, Liver Disease, Serious Heart Condition, Severe Obesity, and possibly others. According to the Minnesota Department of Health, persons who may be at higher risk for severe illness should consider delaying seeking close contact services such as massage. Please check that you understand the following statement and you give consent to receive massage.* This field is required.
“I understand that the MDH recommends persons that are at HIGH RISK of serious complications related to COVID19 should consider delaying seeking close contact services, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner and do not hold the practitioner or T&SRM responsible should I become ill.”
10
If a client or practitioner ends up testing positive for COVID19 after being seen at T&SRM, this office may be required to share information with the Minnesota Department of Health on who may have been exposed to the virus. Please check that you understand the following statement and you give consent to receive massage.* This field is required.
“I understand that my name and contact information may be shared with the Minnesota Department of Health in the event that a client or practitioner at T&SRM 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.”
11
In order for a massage therapy business to open to customers, each business must create a preparedness plan to mitigate the risk of spreading COVID19. In order to accomplish this goal, it relies on the participation of clients in that plan. If you are unwilling to participate in the preparedness plan developed by T&SRM, you will be unable to receive services from this office until such time as the plan is no longer necessary to protect public health and safety. Please check that you understand the following statement and you give consent to receive massage.* This field is required.
“I understand that should I chose not to participate in the Preparedness Plan developed by T&SRM to meet state requirements to reopen, that I will not be able to receive services in this office until such time that the plan is no longer required to protect public health and safety. ”
12
Governor Walz has asked persons of high-risk for complications related to COVID19, as well as all Minnesotans to voluntarily stay home to reduce unnecessary travel. T&SRM respects your need to reschedule, postpone, or cancel your appointment in order to stay home. Please notify T&SRM with your intent to do so within 24 hours of your scheduled appointment time to avoid any late cancelation fees. If you should become suddenly ill, please notify this office at least 1 hour before your appointment time.
13
Date* This field is required.
Date
Month
Day
Year
Should be Empty: