Coronavirus Consent Form

Please review before making your appointment:

Please understand that this company works with the elderly and various other immuno-compromised individuals, so we ask that you sincerely and honestly review, complete and submit this page before your appointment. You may print this page, check off yes or no in the designated areas, sign at the bottom, scan to your computer and email to or bring it to your appointment.

  • If you have been diagnosed with Coronavirus disease (COVID-19) and are taking blood thinners or have skin lesions, please reschedule your appointment for when you have written medical clearance from your physician to have massage therapy.
  • Regardless of your vaccination status, if you answer yes to any of the questions below, we will postpone your appointment without penalty and reschedule you. Further, we recommend you contact your medical doctor. In the last 48 hours, have you experienced:
    • Fever of 100°F or above? Yes_______, No______
    • Respiratory or flu symptoms: (shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea, vomiting or diarrhea)? Yes_______, No______
    • Any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? 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 been traveling or out of the country in the last two weeks? Yes_______, No______
    • Are you worried that you may be ill with COVID-19? Yes_______, No______
    • Have you been in close physical contact in the last 10 days with anyone who is known to have laboratory confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19? Yes_______, No______

If you have answered no to the above questions, have not been diagnosed with Coronavirus disease (COVID-19), or have been diagnosed with Coronavirus disease and are no longer contagious and have a doctor’s note of approval for massage therapy or you have been fully vaccinated and have waited two weeks for your antibodies to build to full strength, you are free to come in:

  1. Arrive early and kindly wait outside until the time of your appointment.
  2. Face coverings are optional. If you prefer the therapist to wear a face covering, please inform us and please feel free to wear a face covering if you wish. We will make sure you are as comfortable as possible.
  3. We recommend that you wash your hands and face before and after your appointment.
  4. When you come in for treatment, we assume you have read and agreed to the Consent for Treatment paragraph below:

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. 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.

_______________________________________________(Printed name)