JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Client Health Screening
Please complete this form 24 hours prior to your appointment
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Date of Service
*
MM
/
DD
/
YYYY
Time of Service
*
Time
:
AM
PM
Phone and/or cell number
*
Your answer
Do you have any of the following symptoms?
*
Temperature above 99.9
Cough
Shortness of breath
Chest pain/pressure
Sore throat
Fatigue
Loss of sense of smell and taste
Rash on skin or discoloration of fingers and toes
None
Other:
Required
Have you or anyone living in your household been- to your knowledge- exposed to Covid 19
*
Yes
No
Are you considered to be a member of the vulnerable population?
*
at risk due to underlying medical conditions (e.g. heart disease, hypertension, diabetes, chronic respiratory diseases, cancer)
at risk due to a compromised immune system from a medical condition or treatment (e.g. chemotherapy
No
Do you have any special requests or other information to share before coming in for a massage treatment?
Your answer
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. This includes but not limited to my exposure or positive test results of Covid 19 or any other related virus, upper respiratory infections or influenza. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. (By checking the agree box below I give my consent to the above mentioned)
*
Agree
Disagree
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
