C&C Honolulu "One Oahu" Screening
Place of business: North Shore Integrated Massage LLC, Waialua, HI

This screening measure is required under the "One Oahu" reopening strategy to prevent the spread of COVID-19.

"If a service provider or client/customer answers “yes” to questions 1-3, they should not provide or receive services at the Provider’s facility. Providers may provide services to those clients/customers who answer “yes” to questions 4 and 5."

If you answered "yes" to any of the questions, see the "Pre-massage Agreement Form" for additional information about how long you need to wait until booking your massage.

This data will be maintained for a minimum of 28 days and is required to be given to State and City health officials upon request.
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Full Name *
Oahu Address: *
Residency *
(For visitors to Oahu) Home address and approximate date of departure:
Phone Number- no spaces, dashes, or parentheses. *
1. Do you now, or have you had in the past fourteen (14) days any of the following: A cough or sore throat? Fever or do you feel feverish? Shortness of breath? Loss of taste or smell? *
2. Are you currently subject to any COVID-19 related quarantine? *
3. Have you had close personal/physical contact with or cared for someone diagnosed with or tested positive for COVID-19? *
If you answered "yes" to any of the above questions (1, 2, or 3) please continue to 4 and 5.
If you answered no to all questions, skip 4 and 5, read the disclaimer and click "I agree," and proceed to sign below.
4. If you answered “yes” to Question 3, are you a health care worker?
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5. If you answered “yes” to Question 4, are you cleared to work at your healthcare facility?
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Massage therapy and the effects of COVID-19 have not been studied in relation to each other. Because massage involves touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By electronically signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from North Shore Integrated Massage. *
I understand that FACE MASKS ARE REQUIRED at all times during the session, and I must bring my own water to drink if necessary. Massage therapy should be avoided for the first 48 hours after receiving any vaccine for COVID-19. *
The information provided on this form will be used for all future appointments, and I will immediately update the therapist regarding any status changes for the purposes of COVID-19 screening. *
Enter any additional information your therapist should know about your health history and preferences for massage.
Signature (Type your name below) *
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