Covid - Bliss Massage & Wellness Center

COVID-19 Intake Form

Name*

Date*

COVID-19: please check all that apply

Have tested positive for COVID-19 (with, or without, symptoms)

Currently waiting for results of a COVID-19 test

Have been exposed to someone who has tested positive for COVID-19

Have recovered from COVID-19

Have had any of the following symptoms in the last 30 days? (fever, shortness of breath, cough, fatigue, chills/shakes, sore throat, new loss of taste or smell, nausea/vomiting, congestion)

If you have selected any of the boxes above, you are ineligible for services at this time. Please call, and we will reschedule your appointment.

I understand the risks of receiving any wellness services at this time, and have answered all of the above to the best of my knowledge. I understand that these questions are intended to ensure the safety of myself and my therapist. Due to the nature of people being asymptomatic unknowingly, I understand and accept the potential that by coming in for treatment I may be exposed to COVID-19

If you are considered to be high risk or having a weakened immune system, we ask that you postpone booking any appointments for the time being, until we have a better understanding of the virus and its complications, as you are at a greater risk of contracting COVID-19.

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