Covid-19 screening
Pierce Doerr Thai bodywork and yoga
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For this to work for everyone, I rely on your honesty in the answers.
First name
Do you currently, or in the last 14 days have a fever (over 100°F)? *
Are you experiencing any of the following signs or symptoms? *
Yes
No
New cough
Sore throat
Difficulty breathing/Shortness of breath
New loss in sense of taste or smell
Nasal congestion or runny nose
Chills
Headaches
Unexplained fatigue or malaise
Nausea, vomiting, or diarrhea
Have you travelled domestically or internationally, or had close contact with anyone who has travelled in the past 14 days? *
Have you had close contact with anyone with a confirmed or probable case of COVID-19 in the past 14 days? *
If you answered yes to any of the above questions, or checked any symptoms on the list provided please reschedule your appointment.
Have you been tested for COVID-19? *
If yes to the above question, was your test positive or negative?
Clear selection
If positive, when did it occur, and are you experiencing any lingering symptoms?
*Waiver - Tribe, A Healing Arts Community LLC and Pierce Doerr have put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you will not become infected with COVID-19 while utilizing the services or while on the premises. [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 from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless Tribe, A Healing Arts Community LLC and my practitioner Pierce Doerr from any claims related thereto. I give my consent to receive treatment from this practitioner. *
Date of appointment? *
MM
/
DD
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YYYY
Time of appointment? *
Time
:
By typing your first & last name below you verify that all information answered in this form is true and complete and agree to the terms of the waiver dated above.
Digital Signature *
Submit
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