Pre-Appointment Health Screen & Liability Waiver

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

Date* This field is required.

Date

4

Do you have any of the following symptoms? Mark any that apply:* This field is required.

New and persistent cough

Shortness of breath or any difficulty breathing

Fever (above 100*F)

A loss or change in your sense of taste or smell.

I have no symptoms.

5

Have you been in contact with anyone in the last 14 days who is experiencing these symptoms (without proper PPE?)* This field is required.Select one.

Yes

No

Not sure

6

Have you been in contact with anyone in the last 14 days who has since tested positive for Covid19 (without proper PPE)?* This field is required.Select one.

Yes

No

Not sure

7

Are you on any blood clotting medication?* This field is required.Select one.

Yes

No

8

Has anything else in your health history changed since your last appointment? (surgeries, medications, injuries, etc.)* This field is required.Write N/A if not applicable.

9

I understand that because massage therapy and bodywork 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.* This field is required.

I understand.

10

I understand that Cassara Grasso, LMT and Flow State Massage & Bodywork LLC cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by the client.* This field is required.

I understand.

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By signing this form, 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 Cassara Grasso, LMT, and Flow State Massage & Bodywork LLC today and for all future sessions. I give my consent to receive treatment.* This field is required.Please type your initials and then hit 'next'.

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Signature* This field is required.

Clear

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