COVID Addendum and Informed Consent
Have you been tested for COVID-19?
If yes, what type of test did you have?
When were you tested?
What were the results?
Have you been in places with a high infection rate (state-designated "hotspots") within the last two weeks?
If yes, please explain.
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the Coronavirus pandemic (approximately January 2020)
Shortness of breath
Diarrhea, digestive upset
Nasal, sinus congestion
Loss of sense of taste or smell
Sudden onset of muscle soreness (unrelated to activity)
Rash or skin lesions (especially on the feet)
Checking the box below confirms the following: 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 that they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.
I have read and confirm the above statements.
I certify that the information I have provided above is accurate to the best of my knowledge.