COVID-19 Health Screening Symptom Checker

COVID-19 Health Screening Symptom Checker

Must Be Completed each day you have a scheduled appointment. Please complete as early as you can once you’ve received this form so that we may secure your appointment for today or so that we may act accordingly for a reschedule in a timely manor. Thank you. This information is bound by HIPPA and data collection for contact tracing and state Heath department data tracking should a need arise.
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
COVID-19 Screening

Best practices to try to minimize the spread of COVID.
BEST PRACTICES; I am grateful for each of you and am asking you to respectfully reschedule should you feel it’s in all of our best interest. We work very hard to stay compliant with The States ever changing guidelines and have taken additional measures in combination with our already high standards in our industries. Every action step helps minimize the chance of contamination though there are no guarantees. Your health, our health and keeping our doors open to safely serve you is our priority. We ask that you kindly reschedule to allow a 10 day quarantine post gathering if you choose to participate in celebrations with friends/ family of more than 10, where social distancing was not practiced/possible, with those from other states, and/or if masks were not worn when in close proximity. This means People who have been within 6 feet for 10 minutes or longer. The 10 minutes of contact can be at one time or cumulative over the course of the day. Thank you for your due diligence and understanding. There is no judgement in your decision: *

We ask if the above statement applies to you that you kindly check this box so that we may assist you in rescheduling. Yes I need to reschedule The above statement does not apply to me. I planned for this and already did a 10 day quarantine. I am fully inoculated see next question. New Hampshire residents who are fully vaccinated against the coronavirus no longer need to quarantine after being exposed to an infected person or after traveling, according to new guidance from the state Division of Public Health Services, quarantine periods are unnecessary if someone is at least 14 days past their second dose of the vaccine.
I am fully Inoculated for Covid 19; 14 days past the inoculation process. Or You have previously tested positive for active COVID-19infection (by PCR or antigen testing) in the last 90 days and have completed your 10 day quarantine. This information is bound by HIPPA and data collection for contact tracing and state Heath department data tracking should a need arise.

Confirmed
Have you had a fever of or above 100.4F in the last 24 hours? Will check on arrival. *

Yes No Did not take at home, please take at time of appointment
Do you currently have, any respiratory or flu symptoms, sore throat, cough, change in your sense of taste or smell, or shortness of breath? *

Yes No
Are you prone to respiratory distress of any kind (if yes please list in other )? *

Yes No
Have you Traveled; internationally, taken a cruise, or domestically taken public transportation outside of NH, Or non essential travel out side New England in the last 14 days. *

Yes No NOTE check here if this applies: You do NOT need to quarantine for 10 days or get tested forCOVID-19 if either of the following apply: 1. You are fully Inoculated against COVID-19 and more than 14 days past the date completed.2. You have previously tested positive for active COVID-19infection (by PCR or antigen testing) in the last 90 days (if you had a previous infection that was more than 90 days ago, you must still follow all quarantine requirements)
Have you or anyone in your household been in close contact with someone who is suspected or confirmed to have had COVID-19 in the past 14 days? *

Yes No
Have you been immune compromised at all in the past week? If yes, please explain in the "other" box below. *

Yes No
Are you or anyone in your direct household waiting for results of a COVID test? *

Yes No
I have had Covid already, I have completed all my doctors recommendations following my positive test, including a 10day quarantine, and have been fever/ symptom free. (If YES, Please fill out the date you were deemed safe to come out of quarantine, either negative result post infection or date last fever free with out symptoms after the 10days min.past 90days is considered a no again. )(If NO simply type NO) *
I consent to being documented as a client here today in the event that contract tracing needs to occur. *

Yes No
I have a clean designated mask/face covering for this treatment to use for my session today. *

Yes No, I need one when I arrive
I will alert you should I have a COVID positive result for myself or in my direct household within 14 days after my session or if I found out that someone I was in direct contact with tested Positive within 14 days prior to my session.
I agree to the above statement. *

Yes No
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures have been put in place to further reduce the spread of this novel virus. However, these best practices still offer no guarantee regarding your potential risk of being infected. PLEASE SEE YOUR SERVICE WAIVER AGAIN, SHOULD YOU HAVE ANY QUESTIONS.
I agree to the above statement. *

Yes No
Consent for Treatment

NEW FORM FOR EVERY TREATMENT
I understand the because Massage and Bodywork involve maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including but not limited to COVID-19. By signing this form, checking yes you understand and/or submiting the form. I acknowledge that I am aware of the risks involved from recieving treatment and voluntarily agree to assume those risks, and I release and hold harmless my practitioner and 444Hands from any claims related thereto. I give my consent to receive treatment and to follow all guidelines asked of me today to keep the practitioner and business compliant.
I agree to the above statement. *

Yes No
Should I not pass my health screening due to potential COVID exposure, since booking this appointment; I understand that Bethany will NOT implement her 24 hr standard cancellation policy and I will not be charged for this appointment as a no show or same same day cancel. *

Yes No
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COVID-19 Health Screening Symptom Checker

COVID-19 Screening

Consent for Treatment