COVID Addendum and Informed Consent

First Name *

Last Name *

Today's date: * +

Have you been tested for COVID-19? *

Yes

No

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? *

Yes

No

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)

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.

Completion

I certify that the information I have provided above is accurate to the best of my knowledge. *

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