Covid-19 Questionnaire and Consent NEW

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 *

New symptoms confirmation

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?

to acknowledge aware

Close contact confirmation

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