Client Intake Form/COVID-19 Information

This intake form contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please answer the following questions:

1. Have you had a fever in the last 24 hours of 100°F or above?  Yes ☐ No ☐  Temp:

2. Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore

    throat, muscle aches, or shortness of breath)?  Yes ☐ No ☐ 

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19

    or has coronavirus-type symptoms?  Yes ☐ No ☐ 

4. Have you traveled anywhere outside of Arizona in the last two weeks?  Yes ☐ No ☐ 

                                               Location:

5. Have you had a new loss of sense of taste or smell?  Yes ☐ No ☐ 

6. Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?  Yes ☐ No ☐ 

Consent for Treatment

To proceed with receiving therapeutic massage, I confirm and understand the following:

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO), is extremely contagious, and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that intensified sanitation and preventative measures to reduce the spread of COVID-19 have been taken by my therapist. However, because this work involves close physical proximity and contact over an extended period of time in a closed space, there may be an elevated risk of disease transmission. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to my therapist to provide care.

I have read, or have had read to me, the above COVID-19 risk informed consent to treatment. I acknowledge that it is not possible to consider every possible complication to care, have had an opportunity to ask questions, and by signing below agree to receive massage therapy today.

Client Signature: