COVID-19 Form - please fill in each time you visit

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Due to the infectious nature of COVID-19, this additional form must be completed before each massage therapy session. Please know that people with COVID-19 can be asymptomatic and still be contagious. There is no way to completely protect ourselves from this virus. You will be asked to sign this checklist 24 hours before EVERY APPOINTMENT. Please answer these questions truthfully and do everything asked so we can do our best to protect each other. Thank you. I appreciate your time and effort to keep us all safe.

Please Note

There is a chance that we will have to reschedule your appointment if necessary, according to your answers below.

Your Name and Date of birth *

Have you had Covid - 19 ? *

Maybe

Yes

If yes, have you got any long haul symptoms?

Yes

Maybe

Other:

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Have you recently been tested for Covid-19? *

Yes

*Are you currently experiencing any of the following symptoms - IF YES, PLEASE CHECK BOX and reschedule *

Fever

Cough

Sore Throat

Shortness of breath

Sudden loss of taste and smell

Fatigue

Chills

Nasal or sinus congestion

Sudden onset of body aches

New rash or other changes to your skin

Unusual new marks or bruises on your legs or toes

Any circulatory issues - varicose veins or pain in calf muscles

NONE OF THE ABOVE

Required

Have you had the Covid -19 vaccine? *

Yes.. first dose

Yes, both doses

If yes, when did you receive the vaccination? If less than two days ago, it is best to reschedule so that you are not uncomfortable.

*Are you aware of having been exposed to someone with COVID-19 or anyone who has been exposed to someone with COVID-19 in the past 10 days? If yes, please reschedule. *

Yes

Other:

Requirement: Are you willing to wear a face mask from the time you enter the property, to the time you leave, and during the whole session? *

Yes

Your signature on this form and your COVID 19 form; is an agreement that you have answered all questions honestly and are aware that your appointment may need to be rescheduled, and that you are willing to wear a mask and that you have been informed and you are consenting to treatment, and you are releasing all liability from Aloha Flow and any people at the premises. Please TYPE FULL NAME BELOW TO AGREE *

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