Appointment Screening Form

Client First Name

Client Last Name

Today's Date

Client Phone

Client Email Address

To protect your health and the health of others visiting and working at our center, you are required to complete this screening 24-48 hours before each massage session. In addition to this screening, you will also be required to have your temperature checked via a touchless thermometer prior to your service. If your temperature is 100.4 or higher, your appointment will be rescheduled. Thank you for your cooperation and for helping us keep everyone safe and healthy!

Please answer the COVID-19 related health questions below:

Do you currently, or have you recently had, any respiratory, flu or cold symptoms including fever, chills, nasal drainage/congestion, sore throat, cough, muscle aches, or shortness of breath?

Yes No

Have you recently lost or had a reduction in your sense of smell or taste?

Yes No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has had any of the symptoms listed above?

Yes No

Do you have any new chest discomfort or pain with exertion or exercise?

Yes No

Have you seen any new rashes or lesions on your skin (especially on the feet)?

Yes No

Have you received a COVID-19 vaccine in the past three days or are you scheduled to receive it before your appointment? If yes, please call and reschedule your appointment. Massage is contraindicated during the 72 hours following a dose of the vaccine.

Yes No

Have you or anyone in your household been tested for COVID-19 in the last 14 days or been diagnosed with Covid in the last 30 days?

Yes No

If yes, what was the result of the test or when were you or the person diagnosed?

If you have answered yes to any of the questions above, you may be required to reschedule your appointment for a date at least 14 days in the future.

I declare that the information provided above is true and accurate to the best of my knowledge.

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Date

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