Wellbliss Massage Precautionary COVID-19 Intake Form

Precautionary COVID-19 Intake Form

Due to the COVID-19 outbreak we are taking extra precautions when it comes to the safety of our clients and practitioner. With that in mind we have expanded how we intake clients and review their health history. Please keep us updated by completing the following and sign below.
Have you had the Covid 19 vaccination?

YesNo
Below are some of the symptoms of COVID-19. Please check if you are experiencing any of the following symptoms:

FeverFatigueDry coughDifficulty breathing
Please agree to the following statements below: If all boxes are not checked, we regret to inform you that your appointment will be cancelled until further review.*

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days.I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.I understand that Wellbliss Massage 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.
By signing below I agree to each above statement and release the massage therapist and Wellbliss Massage from any and all liability for the unintentional exposure or harm due to COVID-19.

I also understand that, because massage therapy work involves maintaining 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 risk involved and give consent to receive massage and bodywork from Kerrie Steil.

Your massage therapist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
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Name*

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Signature*

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