Covid-19 Questionnaire and Consent

ALL FIELDS ARE REQUIRED:

Your email

Have you experienced any NEW symptoms in the past week:

* fever or chills * cough * shortness of breath or difficulty breathing * fatigue * muscle or body aches * headache * loss of taste or smell * sore throat * congestion or runny nose * nausea or vomiting * diarrhea *

YesNo

Have you been in close contact within the last 14 days with:

  • Anyone who has been exposed to Covid 19 or has a confirmed case of Covid-19?

  • Anyone who has symptoms consistent with Covid-19?

YesNo

I understand that there is risk of Covid-19 transmission due to close physical proximity during Rolfing treatment. I acknowledge that I am aware of the risks involved and give my consent for treatment.

Date

Your name to represent your signature