Covid Health Forms

In addition to our having an  up to date Health Intake form for you,  (NEW CLIENTS must bring a filled in Health Intake with them to their first appointment) we will also need you to fill out the following two forms, which you can print out (click on the link) and bring with you (preferred) or fill in when you get here.

  1.  Health Attestation Form
    1. In this form you attest to your health over the last 14 days, Lack of the symptoms listed below,  and lack of any known contact with anyone sick or with these symptoms  in the last 14 days.  You also release The Gentle Place of any liability if you are to get sick.
    2. Symptoms (new or progressive) that disallow massage:
      1. fever
      2. fatigue
      3. flu like symptoms including muscle aches or head pain
      4. abdominal pain, diarrhea, appetite loss, nausea and/or vomiting
      5. shortness of breath
      6. cough
      7. sore throat, runny nose/nasal congestions
      8. loss of smell or taste
      9. “covid toe”
      10. Rashes
  2.  Informed Consent Form:
    1. In this form you acknowledge your understanding of the risk factors of Covid -19 in our community and the health factors that might increase your risk.  It also acknowledges your responsibility to inform us if you get sick, and to be part of the contact tracing system!
    2. IF YOU HAVE ANY OF THE RISK FACTORS BELOW that increase your risk of increased symptoms should you get the disease, we urge you to speak with your Doctor about whether or not massage is right for you and confirm you are  comfortable with the risks before coming in for your massage.
      1. People 65 years or older
      2. People who live in a nursing home or long-term care facility
      3. Chronic lung disease
      4. Moderate to severe asthma
      5. Cardiovascular conditions (including blood clotting issues)
      6. Compromised or suppressed immunity
      7. Severe obesity (BMI 40 or higher)
      8. Diabetes
      9. Chronic kidney disease
      10. Liver diseases

 

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