Coronavirus Intake form for Massage Therapy

COVID-19 Informed Consent & Health Status

Please complete prior to your first visit.
Name *

First Name Last Name
Phone Number *

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

Are you or any members of your household experiencing any of the following symptoms? Please check all that apply. *

	Yes	No
congestion
cough
diarrhea
fever
shortness of breath
sore throat
sudden loss of taste and/or smell
wheezing
nausea or vomiting
severe fatigue
No one in my household is experiencing any of the above symptoms

Do you believe that you or a member of your household was exposed to COVID-19 in the past 14 days? *

Yes No
Have you gathered with people outside of your household in the past 14 days without wearing masks?Choose *

Yes No
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 vaccinated for COVID-19?

Yes, I have received 1 dose Yes, I have received both doses No, I have not been vaccinated
I affirm that I, as well as those in my household...

have not been diagnosed with COVID-19 within the last 14 days. have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 14 days.
Signature

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