Client COVID-19 Information & Consent

Client COVID-19 Information & Consent
Name

First NameLast Name
1) Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days?*

NoYes
1) Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days?*

NoYes
2) Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem) or loss of taste or smell?*

NoYes
3) Have you had close contact with or cared for someone diagnosed with COVID-19, or someone exhibiting cold or flu-like symptoms within the last 14 days?*

NoYes
4) Have you been tested for COVID-19?*

NoYes
When were you tested? *

MonthDayYear
Date
What type of test did you have? *
What was the result:*
GPSW Pain Diagram
Draw on Image
INFORMED CONSENT

I understand that COVID-19 is highly contagious and still present in the community where I am seeking massage therapy. I understand that COVID-19 is passed through close contact with others and that people without symptoms may be infectious. I understand that this massage practice has taken every precaution to ensure my health and safety, but that risk of infection is still possible. I acknowledge that I am aware of the risks involved and give consent to receive massage from this massage therapist.
HIGH RISK AWARENESS

I understand that the health conditions listed below place me at higher risk for serious COVID-19 infection. If I have one of these conditions, I should forgo massage therapy while COVID-19 is still present in my community or obtain my physician’s consent. Should I decide to proceed with massage therapy, I assume all risk related to COVID-19 infection.
DEPARTMENT OF HEALTH AND EXPOSURE TO COVID-19

I understand that in the event that a client, therapist, or staff member of this facility tests positive for COVID-19 within a time period that places me at risk of exposure, my name and contact information will be shared with the State Department of Health for their follow-up. In the event that I develop symptoms of illness within two weeks of my massage appointment, I will contact this GPSW immediately.
Signature*

Clear
Date*

MonthDayYear
Date
HEALTH CONDITIONS THAT INCREASE RISK OF SERIOUS COVID-19 INFECTION
- People 65 years or older
- Chronic lung diseases
- Moderate to severe asthma
- Cardiovascular conditions
- Compromised immunity
- Suppressed immunity (e.g., medication)
- Severe obesity (BMI 40 or higher)
- Diabetes
- Chronic kidney diseases
- Liver disease
Should be Empty: