Effective June 1, 2020
Please fill out & submit this form the morning of EACH appointment.
Respiratory intake form for massage
For all of our safety, please fill this out within 24 hours of your massage - preferably the morning of your massage (for each massage until further notice). Be sure that the information you give is honest, accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
I agree to the following:
I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days.
I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.
In the past 14 days, I have experienced...
Fever of 100.4°F +
Unexplained body aches or pain
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Non-allergy related runny nose
Informed Consent for Prolonged Expisure
I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from Anna McCullough, LMT.
Should be Empty: