Precautionary COVID-19 Health Check Form
Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices.
Please complete the following at your first appointment post COVID break. I will have a copy for you to sign.
Please complete the following at your first appointment post COVID break. I will have a copy for you to sign.
Symptoms of COVID-19 include:
- Fever
- Fatigue
- Dry cough
- Shortness of breath/difficulty breathing
- Chills
- Nausea or vomiting
- Diarrhea
- Confusion
- New widespread muscle pain
- Headaches
- Loss of taste & smell
- Bruising, redness, swelling, or cramping in lower legs and feet
- Red or purple toes
|
Y / N
Y / N Y / N Y / N |
Have you or anyone in your household experienced the above symptoms within the last 14 days? Y / N Have you or household members been diagnosed with COVID19 within the last 30 days?
Have you or any household members knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days? 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 agree to inform my therapist in the future if the answers to any of these questions change: if I experience any of the above symptoms, if I am diagnosed with COVID-19 or if I come into contact with anyone diagnosed with COVID-19. Your massage therapist agrees that they abide by these same standards and affirms the same. Your therapist also affirms the improved and expanded sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions. By signing below I agree to each above statement and release the massage therapist and business from any and all liability for the unintentional exposure or harm due to COVID-19. Signature _________________________________________________ Date ____________ |
If you'd like to print and sign on your own - please download below. If not, I will have a copy for you in my office.
| Precautionary COVID Health Check |