COVID-19 Information & Liability Waiver
Client Name: ______________________________________Date: ____________________________________________
COVID-19 Information
1.Have you had a fever in the last 24 hours of 100°F or above? Yes ☐No☐
2.Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? Yes ☐No ☐
3.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 been practicing social distancing and mask wearing when in public and when you are in 10 ft proximity of others regardless of if they are family (other than those living full time in your home) ? YES NO
Have you been out of the state of Vermont in the last 2 weeks? YES NO
Consent for Treatment:
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.
Client Signature:_________________________________________________Date:____________
Parent or Guardian Signature (in case of a minor):_______________________Date:__________
Massage Therapy Mary Langevin
Statement of Informed Consent
I, , choose to receive massage therapy from Mary Langevin, professionally certified Massage Therapist of Massage Therapy Mary Langevin. I have read and understand the confidentiality and privacy policies of Massage Therapy Mary Langevin.
I acknowledge and understand the health goals in this professional practice. I have provided all information regarding my history of health, any changes of health (including contagious illnesses and/or skin conditions), and medications to my therapist. I am aware of the services and appointment policies of Massage Therapy Mary Langevin. I comprehend the service fees and understand it is my responsibility to communicate in advance for any change in my appointments. I understand I have the right to withdraw from services if I desire to during any time of treatment.
Client Signature Date:
Therapist Signature Date:
Massage Therapy Mary Langevin Intake Form
Name:
Date:
Phone and e mail:
Emergency Contact:
Your address:
Date of birth:
Last massage:
Repetitive physical tasks in your day:
Please explain areas in your body that you recognize a discomfort. Do you have areas of acute pain, numbness, tingling, or soreness?
Are there any areas to avoid today?
Do you have any sensitivity with smell, vision or hearing?
Are you on any medications?
Do you have severe allergies?
Have you had any surgeries?
Is your skin is sensitive (to any oils/ essential oils)?
Please communicate any serious family health issues:
Please note if you have any of the below conditions, feel free to go into any detail.
Recent injury
Contagious skin disorder(s)
Recent illness
Circulation problems
Allergies
Wear contact lenses
Recent surgery
Diabetes
Joint problems
Cancer or undiagnosed growths
Kidney problems
Back problems (disc & other)
High blood pressure
Chronic illness/health problems
Chronic pain
Blood clots
Pregnancy (month)
Varicose veins
Do you have any other information you wish to share regarding to your health and massage session that may enrich the quality of your massage/ improvement of your health?
