In Touch Therapeutic Massage
commited to meeting your specific needs
To best protect your health and the health of others, please fill out this form before each massage and bodywork session. Thank you!
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.