Questionnaire

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Have you have a fever in the last 24 hour of 100.1 F or above? *

Yes No

Do you now, or have you recently had, any respiratory or flu symptoms, headache, sore throat, or shortness of breath? *

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? *

Yes No

Have you been in contact with anyone in the last 14 days who has not felt well, been diagnosed with COVID-19 or has corona-virus type symptoms? *

Yes No

If you answered YES to any of the prior questions, please reschedule your appointment. *

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? *

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. *

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. *

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. *

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. *

Yes I am rescheduling my appointment. Please see notes.

Is there anything you would like me to know? *

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. *

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. *

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. *

Yes I am rescheduling my appointment.

Drinking water will not be dispensed at the office. *

There is no waiting in the reception room. *

Use of the restroom can not be accommodated until you have been screened. *

Your therapist, Lori looks forward to seeing you soon. *

I will see her for our scheduled appointment. I am rescheduling my appointment. I have questions or concerns. See notes below.

Questions or concerns? *

Pre-Appointment Questionnaire​

Pre-Appointment Questionnaire