CoVid-19 Health Declaration Form

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

I am not experiencing any of the following symptoms: Fever or elevated temperature, cough, sore throat, fatigue, new shortness of breath or difficulty breathing, new headaches, new loss of taste or smell, congestion or runny nose, nausea/vomiting, diarrhea

I haven’t tested positive for or experienced symptoms of Covid-19 in the last 5 days, or been in close contact with anyone known or suspected to have tested positive for or experienced symptoms of Covid-19 in the last 5 days(without PPE)

I agree to the following safety protocols: Arrive for my session no earlier than 10 minutes prior to my appointment time, come alone (unless a parent, guardian, or attendant needs to accompany a minor, a client with disability, a translator is needed, etc)

Initials

Date

Mask Update Acknowledgement: Masks are now encouraged, but not strictly mandatory. If you would like your practitioner to mask, let us know via text or email prior to arrival @(510) 761-9460

By receiving bodywork treatments, I attest to the absence of any COVID-19 symptoms, and acknowledge that any bodywork received is always at my own personal risk

Thanks for submitting!