Thank you for completing this form before your appointment.

Confidential Health Intake Form

We ask that you be completely honest in your health intake responses and refrain from coming in if you have any COVID-19 symptoms or other communicable concerns that would be detrimental to the practitioners and other clients in our office.

Your Name

Date of Birth

Mailing Address

City

Zip Code

Phone

Email Address

Occupation

Do you text? Do you text? Yes No

Emergency Contact

Relationship

Phone Number

Have you been confirmed positive with COVID-19? Have you been confirmed positive with COVID-19? Yes No

Have had any COVID-19 symptoms in the last 14 days; fever, cough, shortness of breath? Have had any COVID-19 symptoms in the last 14 days; fever, cough, shortness of breath? Yes No

Have you been in close contact with individuals who have been confirmed positive for COVID-19? Have you been in close contact with individuals who have been confirmed positive for COVID-19? Yes No

Have you recently traveled to an area that is considered a COVID-intensive area? Have you recently traveled to an area that is considered a COVID-intensive area? Yes No

Have you been in contact with other individuals who have traveled to a COVID-intensive area and are exhibiting acute respiratory illness symptoms? Have you been in contact with other individuals who have traveled to a COVID-intensive area and are exhibiting acute respiratory illness symptoms? Yes No

Do you have an Autoimmune Disease? Do you have an Autoimmune Disease? Yes No

Do you experience blood clots? Do you experience blood clots? Yes No

Have/Had cancer? Have/Had cancer? Yes No

Experience abnormal skin condition? Experience abnormal skin condition? Yes No

Do you have High/Low Blood Pressure? Do you have High/Low Blood Pressure? Yes No

Do you have Varicose Veins? Do you have Varicose Veins? Yes No

Do you have Diabetes? Do you have Diabetes? Yes No

Do you experience Headaches or TMJ Do you experience Headaches or TMJ Yes No

Do you have structural/muscular concerns? Do you have structural/muscular concerns? Yes No

Please indicate specifics in structural/muscular Concerns

Please list any other Health Concerns

Current Medications

Signature - Please type your name as an E Signature, indicating that you have read/answered the above questions.

3 + 7 =

Season of Healing Massage & Bodywork

Consent to Treat

I hereby authorize, Season Smith, LMT to provide any and all forms of treatment, evaluation and therapy that may be indicated in connection with my care.
In light of the present conditions associated with COVID-19, I will be honest with my responses when asked about my health during the pre-appointment consultation, and at the time of my appointment.
I understand that my therapist has the right to refuse treatment if she feels that my health condition is not in the best interest of myself or the office at the time of my appointment.
I will not hold Season of Healing Massage & Bodywork, or Season Smith LMT, responsible if I contract COVID-19 knowing that everything possible has been done to prevent exposure, yet there will always remain a risk.
I have been given the opportunity to review the Document “COVID-19 Reopening Guidance, Governor’s Economic Reopening Taskforce” and understand that all guidelines will be met by myself and Season Smith, aka Season of Healing Massage & Bodywork.
I understand that I will be texted or called just prior to my appointment time and will remain in my vehicle until given the okay to enter the building (VIA VERNON STREET), avoiding all surfaces in the shared reception area.
I will wear a face covering upon entering the building and throughout my treatment.

Please type your name as an E Signature, indicating that you have read and CONSENT TO TREAT.