To best protect your health and the health of others, please fill out this form before each massage and bodywork session. Thank you!

NAME:                                                                                                                  DATE:

Have you been tested for COVID-19?

If yes, what type of test did you have?

When was your test?

What were the results?

Have you been in places with a high infection rate within the last two weeks (e.g., state- designated “hotspots”)? If yes, please explain.

Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:

__ Fever __ Diarrhea, digestive upset

__ Chills __ Nasal, sinus congestion

__ Cough __ Loss of sense of taste or smell

__ Sore throat __ Shortness of breath

__ Fatigue. __ Rash or skin lesions (especially on the feet)

__ Sudden onset of muscle soreness (not related to a specific activity)

Do you have any new discomfort with exertion or exercise?

“I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner.”

Practitioners must also alert clients of procedures related to possible exposure to COVID-19. (Initial)_____

“I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.” (Initial)______

I declare that the information provided above is true and accurate to the best of my knowledge.

(print name)________________________

(signature)_______________________

(date)_____