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Have you been tested for COVID-19? *
Have you been to an area with a high infection rate (state-designated "hotspots") within the last two weeks? *
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the Coronavirus pandemic: *
Checking the box below is my declaration that the information provided regarding COVID-19 is true and accurate to the best of my knowledge. *
Contact lenses *
 YesNo
choose yes or no
Allergies *
 YesNo
choose yes or no
Diabetes *
 YesNo
choose yes or no
Cardiac or circulatory problems *
 YesNo
choose yes or no
High blood pressure *
 YesNo
choose yes or no
Joint swelling *
 YesNo
choose yes or no
Arthritis *
 YesNo
choose yes or no
Osteoporosis *
 YesNo
choose yes or no
Varicose veins *
 YesNo
choose yes or no
Contagious infections or diseases *
 YesNo
choose yes or no
Recent broken bones *
 YesNo
choose yes or no
Recent accidents or injuries *
 YesNo
choose yes or no
Recent surgeries *
 YesNo
choose yes or no
Frequent stress *
 YesNo
choose yes or no
Back pain *
 YesNo
choose yes or no
Neck pain *
 YesNo
choose yes or no
Frequent headaches *
 YesNo
choose yes or no
Numbness, tingling or sharp pains *
 YesNo
choose yes or no
Sensitivity to touch or pressure *
 YesNo
choose yes or no
Do you bruise easily? *
 YesNo
choose yes or no
Are you pregnant? *
 YesNo
choose yes or no
Are you taking medications? *
 YesNo
choose yes or no
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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