Health Information - COVID-19 Information & Liability Waiver

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For all of our safety, please fill this out 24 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. Thank you.

Kim Geracioti *

First and last name

Email *

216Phone number (include area code) *

In the past 14 days, I have experienced... Check all that apply. If none of these apply, check "No symptoms". *

Fever 101 F +

Unexplained body aches or pain

Coughing

Sore throat

Shortness of breath

Chills with or without body aches

Recent loss of sense of smell or taste

Unexplained sores on soles of feet

Unusual fatigue

Non-allergy related runny nose

No symptoms

Required

Have you been in contact with anyone who has been diagnosed with COVID-19 or similar symptoms? Is there anyone in your household that is showing symptoms, in self-quarantine, or has been diagnosed with COVID-19? *

Yes

If yes, please explain below.

Consent for Treatment- 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. I acknowledge that I am aware of the risks involved from receiving treatment at this time. I voluntarily agree to assume those risks, and release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner. *

I agree

Required

Print Name as Signature *

Today's Date *

YYYY

Submit

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