COVID-19 Pre-screening

Thank you for scheduling a massage with me. Please complete this form prior to your appointment. I look forward to seeing you soon!

Name*
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Email*
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Phone*
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Address
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Who referred you? How did you hear about me?*
Covid-19 Prescreening
1. Have you been FULLY vaccinated for COVID-19?*
- Yes
- No
Please text me a copy of your vaccine card or bring it to your appointment.
Please email or text me a copy of your vaccination card.
UPDATE: Effective 9/1/21, Urban Body Fitness is requiring proof of vaccination (original or photo of) to the front desk before entering the facility. I am unable to see unvaccinated clients.
2. 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, 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 choose to receive your massage treatment today?*
- Yes
- No
3. Do you agree to notify me immediately if you test positive for coronavirus or are diagnosed with COVID-19?*
- Yes
- No
Date*
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Covid-19 Prescreening