PDF Form

Due to the nature of the coronavirus, a few things have changed since the last time you came in for a massage. One of them being this release form. You must read and fill out this form carefully. If you have any questions, please reach out for clarification.

Please be as honest as possible, none of your answers will automatically disqualify you from receiving massage.

Name

First NameLast Name

Date

MonthDayYear

Email*

example@example.com

Cell Phone Number*

Area CodePhone Number

What are your main reasons for wanting to receive massage today?

1. In the last 24 hours, have you had a fever of 100°F or above? *

2. Do you currently, or in the recent past had, any respiratory or flu symptoms (such as fever, chills, sore throat, cough, muscle aches, or shortness of breath)? *

3. In the last 14 days, have you knowingly been in contact with anyone who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

4. In the last two weeks, have you traveled anywhere outside of the state?*

If yes, where?

5. Do you fall into the vulnerable individual category for any of the following; over 65, chronic lung disease or severe asthma, a serious heart condition, immunocompromised, pregnant, or determined by a health care provider to be at high risk? *

6. Have you experienced a loss of sense of taste or smell? *

The following questions are specific to a new aspect of COVID-19 involving blood coagulation.

7. Can you exercise to get your heart rate and respiratory rate up without any problem? *

8. Have you had a new onset of muscle aches and pain since the emergence of the virus? *

9. Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? *

I agree to:

Cancel my appointment if I am sick.

To proceed with receiving treatment, I confirm and understand the following:

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from a variety of sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision-maker for my health care needs. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent.” It involves my understanding and agreement regarding recommended care and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission for you to proceed with providing care.

I have been offered a copy of this consent form.

I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

Today's Date*

Client Signature or Guardian Signature for Those Under 18*

Kneading Hands