Name                                                                                                                                       

 

Address                                                                                                                                                    

 

Phone Number                                                                                                                                  

 

Medication list                                                                                                                                       

 

Health-Intake Updates

Have you had a fever in the last 24 hours of 100°F or above?   Yes      No

 

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?                               Yes      No

 

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?  Yes    No

I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner.

 

Sign                                                                                                           Date