Health Screening Symptom Checker
Must be completed each time you have a scheduled appointment. Please complete as early as you can once you’ve received this form so that we may secure your upcoming appointment or so that we may act accordingly for a reschedule in a timely manor.
Full Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
Health Screening
Best practices to try to minimize the spread of pathogens.
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 in best practices 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.
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Will do
This information is bound by HIPPA and the data collected for contact tracing and state Heath department tracking should a need arise.
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Understood and I consent
Do you currently have any immunocompromised symptoms; fever of 100.4 in the last 24 hours, respiratory distress, cold or flu signs such as but not limited to, sore throat, cough, congestion, runny nose, change in sense of taste or smell, or any other symptoms today?
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I will reschedule if I’m compromised/sick in any way.
Any non contagious health or body changes I should be aware of? Examples: depression/anxiety, migraines, sports injury, or accident to name a few
No
Other
Are you or anyone in your direct household waiting for test results of any pathogen/contagion?
Yes
No
Masks are optional.
I'm going to wear a mask
We can both wear one please
No mask today
I will alert you should I have a contagious pathogen positive result for myself, my direct household or someone I was in direct contact with, within a 14 day window surrounding either side of my session.
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. 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 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.
Yes, I agree to the above statement
No, I do not agree with the above statement
Should I not pass my health screening due to potential Pathogen exposure, since booking this appointment; I understand that Sarai will use her discretion of implementing her 24 hr standard cancellation policy and will proceed accordingly for this appointment based on early arrangements made for my current health condition.
Yes
No
Signature
Submit
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