COVID-19 Pre-Screening

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In order to be eligible to receive treatment and to attempt to reduce the transmission of COVID-19, you must complete this form with answers to the following questions a minimum of 24 hours prior to your scheduled treatment:

I understand that I must not be in the building more than 5 minutes prior to my session and that any time I am in the building before the start of my session should be used to use the restroom and/or wash my hands thoroughly:

I understand that by choosing to receive bodywork I am increasing my potential exposure to COVID-19:

In the last 30 days, have you or anyone you live with been in direct contact with anyone who has tested positive for or has exhibited the symptoms of COVID-19?

In the last 30 days, have you or anyone you live with been tested for COVID-19 or been required to quarantine yourself due to COVID-19? 

In the last 30 days, have you or anyone you live with been unmasked at an indoor gathering totaling more than 6 people, which included people from outside your household? 

Have you or anyone you live with experienced a fever in the last 14 days?

Have you or anyone you live with felt unusually fatigued in the last 14 days?

Fever or chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea.

Have you or anyone you live with experienced any of the symptoms listed above in the last 14 days?

Have you or anyone you live with traveled outside of the State of Maine in the last 30 days?

Do you agree to wear a protective mask during your session?