Client Intake form
PLEASE READ and make sure that you agreed to the following and acknowledged before scheduling an appointment with me.
1. The therapist and the clients will be wearing appropriate PPE (Personal Protective Equipment) the whole time before, during, and after the session.
2. The body temperature will be measured in person at the clinic with the sanitized digital thermometer with a disposable probe.
3. Clients need to wear an appropriate MASK in the clinic at all times. (Unfortunately due to shortage of mask we can not provide any to the client) The massage therapist will be wearing MASK, GLOVE and other PPE gears necessary suggested by the CDC and Health Department.
4. For the client's safety, for those who have traveled outside the country within 3 weeks, have any suspicious related symptoms and/or have pre-conditions and vulnerable to contracted the COVID-19 PLEASE "DO NOT" schedule any appointment at this time.
Sage Thai Massage
851 W.SR 436 Suite #1045
Altamonte Springs, FL 32714
407-788-7243
Covid-19 Client Intake Questionnaire (********IN PERSON ONLY********)
Initial
1. _______Current Temperature ___________°F _____
2. _______ My temperature has not been above 98.6°F in the past 72 hrs.
3. _______ I have not knowingly been in contact with anyone diagnosed
with Covid-19 in the past 2 weeks.
4. _______ I have not had any of the following symptoms in the past 2 weeks:
Fever, Cough, Shortness of Breath, Persistent Chest Pain, or Pressure.
5. _______ I acknowledge I am receiving Massage Therapy knowing
that social distancing cannot be adhered to during my massage session.
6. _______ In the event I contract Covid-19, I will notify my therapist as soon as possible.
COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. Your Massage Therapist has put in place preventative measures to reduce the spread of COVID-19; however, your massage therapist cannot guarantee that you will not become infected with COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving massage therapy and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my massage therapy appointment. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless my massage therapist, their massage establishment, and any interested parties from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of my massage therapist or the establishment where massage therapy services are received, whether a COVID-19 infection occurs before, during, or after participation in any massage therapy session.
____________________ ____________________
Client Signature LMT Signature
Date ________________ Date ________________