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YOUR CART
Pre-Appointment Questionnaire
Please complete this questionnaire on the day of your appointment, prior to your arrival.
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Indicates required field
Name
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First
Last
Email
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Phone Number
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Have you have a fever in the last 24 hour of 100.1 F or above?
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Yes
No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, headache, or shortness of breath?
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Yes
No
Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?
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Yes
No
In the last 14 days, have you or anyone you have been in close contact with not felt well, been diagnosed with COVID-19, has corona-virus type symptoms, or is waiting for COVID-19 test results?
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Yes
No
If you answered YES to any of the four prior questions, please reschedule your appointment.
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I do not need to reschedule.
I need to reschedule. Please continue with this form and select, "I am rescheduling my appointment."
Is there anything you would like me to know?
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In the last 14 days have you or anyone you have been in close contact with traveled further than 150 miles from home?
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Yes and I/they have have negative covid test result or completed a 10 day quarantine and I can keep my appointment.
Yes. But I/they do not have a covid test result or did not complete a 10 day quarantine and I need to rechedule my appointment.
No
I am rescheduling my appointment.
Date of COVID-19 test and result or end of quarantine.
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In the last 14 days have you participated in any socializing, indoors or outdoors, that included persons not living in your home?
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Yes and I have a negative covid test result or have completed a 14 day quarantine and can keep my appointment.
Yes. But I have not taken a covid test or completed a 14 day quarantine. I need to reschedule my appointment.
No
I am rescheduling my appointment.
Date of your COVID-19 test and result or end of quarantine.
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Consent for Treatment. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By agreeing to proceed with my appointment, I acknowledge that I am aware of the risks involved from receiving treatment at this time. I voluntarily agree to assume those risks, and I release and hold harmless the practitioner and business from any claims related thereto.
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I give my consent to receive treatment.
I am rescheduling my appointment.
Consent to Release Contact Information. I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this office tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on the suspected exposure date.
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I consent to the release of my contact information only for appropriate follow-up by the health department.
I am rescheduling my appointment.
If I develop symptoms of COVID-19 within 2 weeks of an appointment, I agree to inform my practitioner immediately.
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I agree
I am rescheduling my appointment.
When you arrive for your appointment, please wait in your car and text or call your practitioner to let her know you have arrived.
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Yes
I am rescheduling my appointment.
Please see notes.
Select all that apply
Is there anything you would like me to know?
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When your practitioner asks you to come to the office door, please approach her wearing your face mask. Please note, face masks with one-way valve for easy breathing do not meet the CDC requirements and will not be allowed to be worn.
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Yes
I am rescheduling my appointment.
Your therapist will take your temperature using a no-touch thermal temperature scan. If your temperature is 100.1 F or higher, your appointment will be cancelled without charge.
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Yes
I am rescheduling my appointment.
Your therapist will provide hand sanitizer for you to apply prior to entering the office. IF you have skin sensitivities, please bring your own hand sanitizer. IF you are wearing gloves, the gloves will be removed and placed in the trash before applying hand sanitizer.
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Yes
I am rescheduling my appointment.
Drinking water will not be dispensed at the office.
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OK
There is no waiting in the reception room.
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OK
Use of the restroom can not be accommodated until you have been screened.
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OK
Your therapist, Francoise looks forward to seeing you soon.
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I look forward to our scheduled appointment.
I am rescheduling my appointment.
I have questions or concerns. See notes below.
Select all that apply.
Questions or concerns?
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Submit
