COVID-19 Pre-screening - James Dustin

Name*

First Last

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who referred you? How did you hear about me?*

Covid-19 Prescreening

My number one priority is to protect all of my clients from the coronavirus. If you have been exposed to the coronavirus you may spread the it to myself and/or other clients. Therefore, prior to every appointment, I will be asking you to honestly answer the following questions to help reduce the chances of transmission:

Have you, or anyone in your circle of close friends, family or coworkers tested positive for coronavirus or been diagnosed with COVID-19?*

Yes
No

Have you been tested for the coronavirus and/or coronavirus antibodies?*

Yes
No

Have you traveled outside of the US in the past 14 days?*

Yes
No

Have you been following CDC guidelines for social distancing and masks?*

Yes
No

In the past 14 days have you or anyone in your circle of close friends, family or coworkers experienced any of the following:

A fever (defined as 99.6° or higher)*

Yes
No

A cough?*

Yes
No

Shortness of breath/trouble breathing?*

Yes
No

Pain, pressure or tightness in the chest?*

Yes
No

Loss of taste or smell?*

Yes
No

Muscle cramps?Fatigue?*

Yes
No

Any other COVID-19 symptoms?*

Yes
No

As with any communicable disease like a cold or flu, you may be exposed to the coronavirus at any time or in any place. While I am taking the safety of my clients extremely serious, by practicing social distancing and mask wearing guidelines set by the CDC and by employing new safety and sanitation protocols, I am not an expert in the risk analysis of COVID-19 and I cannot guarantee that any of these measures will completely protect you from contracting COVID-19. Do you assume all risks and chose to receive your massage treatment today?*

Yes
No

Do you agree to notify me immediately if you or anyone you are close to tests positive for coronavirus or is diagnosed with COVID-19 so that I may stop all massages, self-quarantine and get tested?*

Yes
No

I agree that I will do the same for you.

Date*