Booking

Name *

First Name Last Name

Have you filled out this form before? *

Yes, and there have been no changes *IN MY HOUSEHOLD* since my last submission No (or yes but there have been changes since my last submission, including someone in my household currently covid positive)

I understand that if a member of my household is currently covid positive, even if I am testing negative, I must text Suzanna ASAP (919-475-9416) so that she can gather pertinent info & make an informed decision. If I do not text Suzanna, I understand my session will be cancelled and I will be charged in full. *

Yes

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

Email Phone (call) Phone (text)

E-mail *

Phone Number *

Area Code Phone Number

What is your vaccination status?

I'm fully vaccinated and boosted! I am not boosted, or I've had one shot of a two-shot series Not yet vaccinated

In the past 14 days, have you experienced:

	Yes
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

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 to enter the office until Suzanna contacts me at the time of my appointment. (I understand I can go into the building to use the restroom if needed!)
I will wash or sanitize my hands upon entering the building and post-massage
I WILL ARRIVE WEARING A FACE MASK, DESPITE VACCINATION STATUS. If I am fully vaccinated, I will have the option to remove the masks when inside Suzanna’s office. If I am not vaccinated, I must wear a mask from the time I enter to the time I leave the building and for the entirety of the session.
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. 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. 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. I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. *

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?

THANK YOU, DEAR CLIENTS!!
THANKS TO YOU ALL, SUZANNA WAS VOTED "BEST MASSAGE THERAPIST IN THE TRIANGLE" 2021 INDYWEEK AWARDS!
⭐️⭐️⭐️⭐️⭐️