COVID-19 Health Questionnaire & Informed Consent

Client Name*

Have you or anyone in your household had a fever in the last 24 hours of 100 or above?

Yes
No

Do you now, or have you recently had, any respiratory or flu symptoms?

(Including fever chills, sore throat, cough, muscle aches, or shortness of breath)

Yes
No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes
No

Have you traveled anywhere outside of the state in the last two weeks?

Yes
No

If yes, where?

Have you had a new loss of sense of taste or smell?

Yes
No

Can you exercise to get your heart rate and respiratory rate up without any problem?

Yes
No

Have you had any new onset of muscle aches and pain since the emergence of the virus?

Yes
No

Have you seen any new marks, rashes, spots, bumps, bruising without cause, or other lesions on your skin?

Yes
No

INFORMED CONSENT

Consent*

To proceed with receiving care, I confirm and understand that the information provided is accurate. I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that this is extremely contagious and may be contracted with a possibility of a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision-maker for my own health care. I understand that while preventative measures and intensified sanitation protocols intended to reduce the spread have been implemented at Massage Innovations, I may still be at risk of disease transmission due to being in close physical contact for an extended period of time in a closed space.

I understand what I have read and give informed consent to treat. I appreciate that it is not possible to consider every complication to care. I agree with the current or future recommendation to receive care as is deemed appropriate for my circumstance. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care and I will notify your office if there are any changes to my health.

I confirm and understand.*

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Name

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COVID-19 Health Questionnaire & Informed Consent

INFORMED CONSENT

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ROCKFORD, IL LOCATION

PRINCETON, IL LOCATION