subject_line
First Name
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Last Name
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Date of Birth
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+
Street Address
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Address Line 2
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone Number
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Can we send text message appointment reminders?
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Yes please
No thanks
Email Address
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Emergency contact name and phone number:
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Have you received a professional massage before?
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Yes
No
If yes, how long ago?
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What are your goals for today's session?
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Have you been tested for COVID-19?
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Yes
No
If yes, what type of test did you have?
When was your test performed?
What were the results?
Positive for COVID-19
Negative for COVID-19
Have you been to an area with a high infection rate (state-designated "hotspots") within the last two weeks?
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Yes
No
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the Coronavirus pandemic:
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Fever
Chills
Cough
Shortness of breath
Sore Throat
Digestive upset, diarrhea
Nasal, sinus congestion
Loss of sense of taste or smell
Fatigue
Sudden unexplained muscle soreness
Rash or skin lesions
None of the above
Checking the box below is my declaration that the information provided regarding COVID-19 is true and accurate to the best of my knowledge.
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Check here
Contact lenses
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Yes
No
choose yes or no
Yes
No
Allergies
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Yes
No
choose yes or no
Yes
No
Diabetes
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Yes
No
choose yes or no
Yes
No
Cardiac or circulatory problems
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Yes
No
choose yes or no
Yes
No
High blood pressure
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Yes
No
choose yes or no
Yes
No
Joint swelling
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Yes
No
choose yes or no
Yes
No
Arthritis
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Yes
No
choose yes or no
Yes
No
Osteoporosis
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Yes
No
choose yes or no
Yes
No
Varicose veins
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Yes
No
choose yes or no
Yes
No
Contagious infections or diseases
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Yes
No
choose yes or no
Yes
No
Recent broken bones
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Yes
No
choose yes or no
Yes
No
Recent accidents or injuries
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Yes
No
choose yes or no
Yes
No
Recent surgeries
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Yes
No
choose yes or no
Yes
No
Frequent stress
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Yes
No
choose yes or no
Yes
No
Back pain
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Yes
No
choose yes or no
Yes
No
Neck pain
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Yes
No
choose yes or no
Yes
No
Frequent headaches
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Yes
No
choose yes or no
Yes
No
Numbness, tingling or sharp pains
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Yes
No
choose yes or no
Yes
No
Sensitivity to touch or pressure
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Yes
No
choose yes or no
Yes
No
Do you bruise easily?
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Yes
No
choose yes or no
Yes
No
Are you pregnant?
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Yes
No
choose yes or no
Yes
No
Are you taking medications?
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Yes
No
choose yes or no
Yes
No
If you have answered "yes" to any of the above questions, please explain here. If not, type "none".
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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 this practitioner. I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or technique may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I also agree to give 24 hours’ notice to change or cancel an appointment, and that no-shows will be charged full session price.
Please sign your full name below to agree with the above statement.
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