COVID-19 PRE SCREENING & RISK INFORMED CONSENT TO TREAT FORM

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Please fill out this COVID-19 PRE SCREENING AND CONSENT FORM on the day every massage before you arrive for your appointment.

This questionnaire/form contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully before your initial session. We will be notified when this is completed.

As always, our primary goal is to provide a comfortable space for my massage practice to continue safely. Please help us save paper and devote more time to your treatment! This form is REQUIRED of all Ola Mau Massage clients. When requested, you will receive a copy of your responses once the form is complete. If you have ANY questions or concerns please don't hesitate to contact us.

*Health Information Privacy
For the purposes of treatment and safety during the Covid-19 pandemic, we do collect and store health information from you. Ola Mau Massage is a HIPPA compliant practice. Your health information is kept strictly confidential meaning we do not share your health information without written permission (unless required by law). If you have any questions or concerns regarding your health records please contact our Safety Compliance Officer at olamaumassage@gmail.com. Read our full Privacy Policy at https://www.olamaumassage.com/privacy

Email *

First *

First Name

Last *

Last Name

Covid-19 Health Information *

yes

Have you had a fever in the last 24 hours of 100°F or above?

Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)?

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Do you now or have you recently had any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

yes

Have you had a fever in the last 24 hours of 100°F or above?

Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)?

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Do you now or have you recently had any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

5. Have you traveled anywhere outside the island of Maui in the last two weeks? *

yes

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