COVID Health Check
Please fill out & submit this form for EACH appointment.
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. This helps me keep everyone safe. Please get immediate medical attention if you have any of the severe COVID-19 signs.
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Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
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...
Yes
No
Fever of 100.4°F +
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose
Informed Consent for Prolonged Exposure
*
I understand that despite all the measures taken to be safe, 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 Ben Burman.
Type your Signature
*
Mr.
Mrs.
Ms.
None
Prefix
First Name
Last Name
Suffix
Date
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Month
-
Day
Year
Date
Submit
Should be Empty: