COVID-19 Questionnaire

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Today’s Date* This field is required. This form must be completed on the day of, and before each massage appointment.
Date
Month
Day
Year
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Client Information* This field is required.
Full Name
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This list is not all inclusive. Please cancel or reschedule your appointment if you or your anyone in your household currently has/had any of the following symptoms within the LAST 72 hours.Clicking on the image below will route to the CDC's "Symptoms of Coronavirus" webpage
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I agree to the following:* This field is required.
1. I understand the symptoms from the previous slide and affirm that I, as well as all household members, do not current have, nor have experienced the symptoms listed within the LAST 14 DAYS.
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I agree to the following:* This field is required.
2. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE PAST 14 DAYS.
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I agree to the following:* This field is required.
3. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 14 DAYS.
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I agree to the following:* This field is required.
4. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 14 DAYS.
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I agree to the following:* This field is required.
5. I understand that Customized Massage, LLC cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.
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COVID-19 Liability Waiver* This field is required. I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Customized Massage, LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I voluntarily seek services provided by Customized Massage, LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I hereby release and agree to hold Customized Massage, LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the clinic, or that may otherwise arise in any way in connection with any services received from Customized Massage, LLC. I understand that this release discharges Customized Massage, LLC from any liability or claim that I, my heirs, or any personal representatives may have against the clinic with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Customized Massage, LLC. This liability waiver and release extends to the clinic together with all owners, partners, and employees. I further acknowledge that Customized Massage, LLC cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, clinic staff, and other clinic clients and their families. By signing below, I agree to each statement above and release Customized Massage, LLC from any and all liability for the unintentional exposure or harm due to COVID-19. Customized Massage, LLC agrees to abide by these standards and affirms the same.
ClearSign by using a touch tablet/screen or left click and hold as you sign with your mouse.
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