• COVID-19 Daily Screening Questions

  • Please have this form filled out and submitted at least 1 hour prior to your appointment.

     

    Upon entering the building please wash your hands for 20 seconds with warm soapy water. The bathroom code is 3808

     

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • In the past 14 days, have you traveled outside of the states or to a hotspot in the states? If yes, please describe the covid precautions you took while traveling. You can elaborate in the box at the end of this survey or in the "other" box.*

  • Have you been tested for Covid-19 in the past 14 days because you have had symptoms?*

  • Do you work in close contact, live, or pod with anyone with a positive or presumptive covid-19 case or anyone with a cold/flu or symptoms thereof?*
  • Do you have you had a NEW or WORSENING:*
    Rows


  • If the answer to any of these questions is yes, please elaborate in the box below.

     

  • If you have recently been sick, not with Covid-19, please refrain from coming in for your massage until it's been at least 10 days from the onset of symptoms and you've been symptom free for 24 hours without medication.*
  • Within the past 10 days have you been to a crowded indoor or outdoor event, bar, club, wedding, show, etc. where social distancing was not possible?*

  • I agree to wear a well fitted mask without a vent for the duration of my appointment regardless of vaccination status. If you are wearing a surgical mask, the colored part of the mask faces outward. Please make sure your mask has wire to fit snuggly around the nose or consider double masking if your mask fits losely.*
  • Clear
  • Should be Empty: