Coronavirus Intake form for Massage Therapists

Register for Covid-19 Test

Please review and acknowledge the following important information
1. The test detects if you have SARS-CoV-2 (the virus that causes COVID-19) at the time of the test only. It does not test for immunity or if you had the virus in the past.
2. If your results are positive, please contact a doctor immediately.
  Only a doctor can give you a diagnosis. They can also provide information on how to care for yourself and to help protect others from infection.
3. Negative results mean that the virus was not detected.
  If you're feeling symptoms, contact a doctor and ask whether you should be retested because:
  
  a. You may have contracted the virus after your test.
  
  b. Your test may have been a false negative. False negatives occur because the tests are not perfectly accurate.
4. We do not provide medical advice or medical care. Please follow up with your primary doctor about your results.
Your results will be shared with certain federal, state, or local agencies for public health purposes as required by law.

Personal information

This is used to prepare test results and to support city and state officials who are collecting data to understand how COVID-19 is impacting communities.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CONTACT INFORMATION

This information will only be used to communicate with you about your test results.
Email *
example@example.com
Phone Number *

Area Code Phone Number
*Results will be sent via email.

Race and Ethnicity

An answer is required by the US Centers for Disease Control and Prevention (CDC). It helps understanding the impact of COVID-19 across our community.
Race *
Ethnicity *

	Yes	No	Not sure
Fever 101°F +
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

Register for Covid-19 Test