COVID-19 PRE-SCREENING & INFORMED CONSENT
PLEASE REVIEW OUR STUDIO COVID-19 POLICIES & PROTOCOLS PRIOR TO BOOKING. CLICK HERE: https://www.indigoandivynh.com/covid
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Have you had a fever in the last 24 hours of 100°F or above?
*
Yes
No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
*
Yes
No
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
*
Yes
No
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
*
I agree with the above statement
I disagree with the above statement.
Signature
*
Submit
Should be Empty: