Massage Evolved COVID-19 Intake Form

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This form is meant to be completed no more than 24 hours in advance of your scheduled massage. If you develop symptoms of COVID-19, or a close contact develops symptoms, after completing this form, please contact us to reschedule your appointment with no cancellation fee.

First and Last Name

Are you currently experiencing or have recently experienced any of these symptoms?

Cough

Shortness of breath or difficulty breathing

Fever of equal to or greater than 100.0 degrees Fahrenheit

Chills, with or without shaking

Muscle pain and aches (from illness)

Abnormal headache

Sore throat

Loss of taste or smell

Diarrhea

Other:

Have you had a COVID-19 positive test or presumed positive assessment from a doctor?

Yes

Clear selection

If yes to above, which of the following are accurate (you may select more than one). Please include any relevant details in the Other field.

You've since had a negative test

You've been cleared by a doctor or medical personnel to end quarantine

You haven't had symptoms for more than 72 hours

You still are experiencing minor symptoms

Other:

Have you had known close contact with a person who is lab-confirmed to have COVID-19 with the last 14 days?

Yes

Maybe

Clear selection

In the event that I develop symptoms or test positive for COVID-19 within 14 days after my appointment, I agree to contact Massage Evolved to assist in quarantine efforts for the health of massage therapists and other clients.

Yes

Clear selection

I give permission for my name and contact information to be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department. (This is optional and your personal choice)

Yes

Clear selection

I understand that if I arrive for my appointment with any possible symptom of COVID-19, I will be refused service. I agree to comply with all screening and safety precautions required by Massage Evolved, including (1) wearing a properly fitted mask over my mouth and nose for the entire duration of my visit, except while face down on the massage table, (2) having my temperature taken with a no-contact forehead or wrist thermometer, and (3) not bringing any companion or children to the appointment.

Yes

Clear selection

I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there is an elevated risk of disease and illness transfer, including COVID-19. I acknowledge that I am aware of the risks involved from receiving massage at this time. By signing this form, I voluntarily agree to assume those risks, and I release Massage Evolved LLC and associated licensed massage therapists from any related claims or lawsuits related to potential exposure to Coronavirus and COVID-19.

Yes

Clear selection

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by visiting Massage Evolved and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Massage Evolved may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, contractors, and clients. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my visit to Massage Evolved (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless Massage Evolved, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions or omissions of Massage Evolved, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after a visit to Massage Evolved.

Yes

Clear selection

By entering my legal name into the field below, I certify my understanding of and agreement with the above policies.

Today's Date

YYYY

Submit

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