TMC Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

TMC Intake Form

Please complete this form if you are interested in scheduling a session or class at The Metta Center

Email *

Name and Address: *

Phone Number *

Date of Birth *

What are you interested in scheduling? *

Massage Therapy

Yoga Therapy

Yoga Classes

Other:

Required

Have you had a fever in the last 24 hours? *

Yes

What is your normal body temperature? *

Do you know your O2 Saturation level? (Pulse Ox) *

yes

Do you now, or have you recently had any respiratory or flu like symptoms, sore throat or shortness of breath? *

Yes

Maybe

Have you been in contact with anyone who has been diagnosed with COVID19 within the past 14 days or who has Corona virus like symptoms? *

Yes

Maybe

Where have you traveled in the past 2 weeks? *

I agree to: *

Wear a face mask while at The Metta Center

Wash my hands upon entering the studio

Have my temperature taken with a touchless thermometer upon arrival

Have my O2 Saturation level taken with a pulse ox monitor upon arrival

Pay for my session and leave in the event I arrive symptomatic or feeling ill

Arrive wearing clean clothing that has not subject to exposure

Arrive on time, but not too early- and if arriving early, wait in my car until the appropriate time

Communicate with my teacher/practitioner should I become diagnosed with Covid19 within 2 weeks of my visit

Hold harmless the studio and staff of The Metta Center in the event I suspect to have contracted Covid19 during a visit/session/class

Required

Release of all claims: This release is intended to discharge in advance The Metta Center, Lise Flora Waugh, Abby Staten, and Sam Dart from and against any and all liability arising out of or connected in any way with my participation in classes or private sessions of any kind at The Metta Center, even though that liability may arise out of the negligence or carelessness on the part of these facilities or its servants, agents or employees. I further understand that accidents occasionally occur during the performance of Yoga or Yoga Therapy. Knowing these risks, I assume those risks and agree to release and hold harmless this facility (The Metta Center) and all the practitioners therein. I further understand and agree that this waiver, release and assumption of risk shall be binding upon my heirs, executor(s) and successors. Additionally, I fully understand that Covid19 is a contagious pathogen and agree to hold harmless this studio and it's practitioners and other clients in the event I should be diagnosed with Covid19. Please acknowledge by selecting AGREE below: *

AGREE

Required

Thank you for taking your time to fill this form in. This information will only be used for your benefit and will not be shared. Please leave any additional comments here.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms