Coronavirus Intake form for Massage Therapists

COVID-19 Informed Consent & Health Status

For all of our safety, please fill this out 24 hours prior to each massage (until further notice). Be sure that the information you give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
Phone Number

Area Code Phone Number
Your Appointment Date *

Month Day Year
Date
I understand that close contact with people increases the risk of infection from Covid-19. I acknowledge that I am aware of the risks involved and give consent to receive massage.
I understand that my name and contact information may be shared with the state health department if a client or practitioner at this facility tests positive for Covid-19. My information will only be shared in the event that it is relevant based on suspected exposure date, and only for appropriate follow up by the health department.

In the past 14 days, have you experienced any of the following...

Yes

Fever

Unexplained body aches or pain

Coughing

Sore throat

Shortness of breath

Chills with or without body aches

Recent loss of sense of smell or taste

Unexplained sores on soles of feet

Unusual fatigue

Non-allergy related runny nose

Diarrhea - Digestive upset

Rash or skin lesions

Sudden onset of muscle soreness
(not related to activity)

Have you been tested for Covid-19

Yes No
If 'Yes' when was your test?

Month Day Year
Date
What were the results?

Positive Viral Test Positive Antibody Test Negative
Have you been in areas with a high infection rate within the last 14 days (eg: state designated "hot spots")

Yes No
I affirm that I, as well as those in my household...

have not been diagnosed with COVID-19 within the last 30 days. have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.
Signature

Clear
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