Confirmed or Probable COVID-19 Survivor Consent Form

375 Bay Road Suite 104 Queensbury. NY 12804

518-615-4622
COVID-19 Probable or Confirmed Survivor Consent Form

***PLEASE Fill Out 24 hours BEFORE coming in for your appointment to AVOID cancellation of your scheduled appointment.***
Because COVID-19 is a NEW phenomenon with lots of variations, safety is very important when receiving massage therapy and bodywork AFTER recovering from COVID-19. Blood clotting is one important issue that you as a COVID-19 survivor may face. Answering the following questions will be the most important information you can provide to help in making sure that we keep your massage and bodywork safe and within the limitation your body can tolerate.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Email*

Confirmation Emailexample@example.com
What is your preferred method of communication, especially on short notice?*

Text MessageEmailPhone Call
Date of Positive Test Results or Probable Infection*
Month/Day/Year
Name, Address and Phone Number of Your Medical Doctor*
What does your medical doctor advise about getting physical activity? *
PLEASE explain to the best of your ability the advice given.
What do you DO in terms of physical activity? Are you exhausted afterward?*
PLEASE explain what you do on a daily basis.
Do you have any NEW (that is, since your infection) experience of SEVERE deep muscle or joint pain -unrelated to recent physical activity? *
If YES, PLEASE explain.
Do you have any NEW (that is, since your infection) discomfort with exertion? Ex. Chest Pain, Dizziness, Shortness of Breath, Headache or Cramping in a New Pattern.*
If YES, PLEASE explain.
Are you taking ANY drugs to manage blood clotting?*
If YES, PLEASE write the name of the drug.
What other LONG TERM CONSEQUENCES of your infection affect your life?*
PLEASE write how your life is affected.
I AFFIRM that at have answered ALL questions on this form truthfully and honestly so that the safest massage therapy session can be given. I give my consent for my massage therapist, Grace McDonald, to contact my medical doctor above, if necessary, to ask any questions relating to their medical advice and treatment in order for my therapsit to determine how to safely proceed with my massage therapy session.
Client Signature*

Clear
Today's Date*

MonthDayYear
Should be Empty:

375 Bay Road Suite 104 Queensbury. NY 12804

COVID-19 Probable or Confirmed Survivor Consent Form