COVID-19 Pre-Screening

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:

Name(required)

Email(required)

Phone(required)

Today's Date(required)

Date of Appointment(required)

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

Choose one

Yes No

In the last 14 days, have you or anyone you live with experienced or been in direct contact with anyone who has tested positive for or has exhibited the symptoms of COVID-19?

Choose one. If you choose "yes," please explain in the notes field below:

Yes No

In the last 30 days, have you or anyone you live with traveled internationally?

Choose one. If you choose "yes," please explain in the notes field below:

Yes No

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

Choose one

Yes No

Notes