Booking

Name *

First Name Last Name

Have you filled out this form before? *

Yes, and there have been no changes since my last submission No (or yes but there have been changes since my last submission)

Best way to reach you on the day of the appointment *

Email Phone (call) Phone (text)

E-mail *

Phone Number *

Area Code Phone Number

In the past 14 days, have you experienced: *

Yes

No

Fever >100ºF

Coughing

Sore Throat

Shortness of breath

Chills with or without body aches

Recent loss of sense of smell or taste

Unusual fatigue

Other respiratory symptoms

In the past 14 days, have you been in contact with anyone who has been diagnosed with COVID-19 or who has had the above symptoms? *

Yes No

Please indicate travel you've done in the last 14 days:

Air travel (domestic or international) Another type of travel to places with a high infection rate

Did you wear a mask and follow social distancing to the best of your abilities during your trip?

Yes No Sometimes

Do you spend time around anyone considered high risk, such as elderly or immunocompromised family members? *

Yes No

Please indicate that you agree to each each of the following actions on the day of your appointment. *ALL OF THESE ACTIONS ARE REQUIRED* *

YES

I will wait in my car (or socially distanced outside) until Suzanna contacts me at the time of my appointment. I understand I can go into the building to use the restroom if needed, but I will return outside afterward until I hear from Suzanna.

I will bring as few items into the treatment room as possible

I will wash or sanitize my hands upon entering the building and post-massage

I will wear a face mask for the entirety of the session and time in the building.

If I feel ill on the day of my session, or if I am concerned I might have been exposed, I will contact Suzanna as soon as possible. I understand there is no penalty for canceling my appointment if I'm feeling sick.

I consent to contactless payment BEFORE OR AS SOON AS POSSIBLE AFTER the session. I understand that when I submit this form, an email will be sent to me with payment options.

Beginning Jan 2021, I understand that there will be a $5 fee per day added to the session cost for late payment over 24hrs.

(Suzanna accepts all credit cards (via Square), Venmo, check, and cash. I understand Suzanna will not have cash on hand for making change.)

I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. *

Yes No

I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. *

Clear

Is there anything else you'd like Suzanna to know before your session?