COVID Daily Checkpoint

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A daily checkpoint for staff, students, and guests to assess exposure risk in relation to COVID-19. (Please complete before entering the building. You may check in by phone once this checkpoint is complete.)
Please call 517-662-4140 to check in.

Today's Date: *

YYYY

My reason for visiting ASM: *

I work here.

I am a student.

I am here to receive massage therapy.

Other:

Required

SummerMy First & Last Name: *

My Phone Number (numbers only) *

Within the last 14 days, have you experienced any new respiratory or flu symptoms such as cough, sore throat, or shortness of breath? *

YES

Within the last 14 days, have you experienced any new loss of smell or taste? *

YES

Within the last 14 days, have you experienced any new chills or muscle aches? *

YES

Within the last 14 days, have you experienced any new rashes or lesions? *

YES

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

YES

Do you currently have a fever above 100°F (or have you had one within the last 14 days)? *

YES

I agree to report COVID-19 diagnosis. *

I agree

I do NOT agree

I understand that close contact with people increases the risk of infection from COVID-19. By selecting "YES", I acknowledge that I am aware of the risks involved and give consent to receive massage therapy and/or training at ASM. *

YES

I understand that my name and contact information might be shared with the state health department in the event that a client, student, or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event that are relevant based on suspected exposure date, and only for appropriate follow-up by the health department. *

YES

I release ASM from liability in accordance with this policy. *

YES

Thank You!

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