Coronavirus Intake form for Massage Therapists

Health questions and mandates for massage

For all of our safety, please fill this out 24-48 hours prior to each massage (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number

In the past 14 days, I as well as any household members have experienced...

	Yes	No
Fever 100°F +
Unexplained body aches or pain
Coughing
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unusual fatigue
Non-allergy related runny nose
New rashes
Red or purple toes
Redness, swelling, or cramping in lower legs and toes
Nausea, vomiting or diarrhea

In the past 14 days, I or any household members have...

	Yes	NO
Tested positive for COVID 19
Knowingly been exposed to someone with COVID-19
Traveled outside the country or to any state that has been considered a "hot spot" for COVID -19 infections

I understand that for my appointment I will...

wait in my car until 5 minutes before the start of my appointment then will meet my therapist at the office door. have my temperature taken with a contactless thermometer at the door be required to wear a mask the entire duration of my appointment including during the massage (one will be provided if needed) call to reschedule if I am not feeling well without penalty of a cancellation fee prevent the spread of droplets by keeping conversation limited to massage pressure and comfort. This will also help me relax.
What is your COVID vaccination status *
Please come prepared to show your vaccination card if applicable (being vaccinated is NOT a requirement to receiving services!)
By signing below I agree that all of the above statements are accurate and truthful, and release the massage therapist and business from any and all liability for any unintentional exposure or harm due to COVID-19. I also affirm knowledge that even though these safety measures are in place, there is no guarantee that I will be safe from contracting COVID-19 since massage cannot be received from the recommended social distance of 6 feet away. I accept any and all risks while receiving this massage.

Your massage therapist agrees to abide by these same standards. Your massage therapist also affirms that she has met or exceeded sanitation protocols as set by the State of Massachusetts and CDC guidelines to fight the spread of COVID-19 and other communicable conditions.
Signature

Clear
Date

Month Day Year
Date
Thank you so much for the opportunity to be your massage practitioner!

With gratitude, Dot Mersfelder
Please click the SUBMIT button below
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Health questions and mandates for massage