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COVID-19 Survey Intake Form for Massage Therapy Form
Please fill out the form
Respiratory intake form for massage
For all of our safety, please fill this out within 24 hours of your massage - preferably the morning of your massage (for each massage until further notice). Be sure that the information you give is honest, accurate and complete. Please get immediate
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Full Name:
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First Name
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Last Name
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Mobile No:
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Invalid phone number.
The value must be less than or equal to 20
Date:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
I agree to the following:
I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days.
I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.
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In the past 14 days, I have experienced...:
Yes
No
Fever of 100.4°F +
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose
I agree that I am providing accurate health information.
I agree that I am providing accurate health information.
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Informed Consent for Prolonged Exposure
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 Anna McCullough, LMT.
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 Anna McCullough, LMT.
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Signature:
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Submit
