COVID questions for first-time clients "*" indicates required fields Because you are scheduled for an appointment in person, please fill in this form before scheduling your appointment. Thanks very much. (You must answer all the questions in order to submit the form.)My Name:* I acknowledge that I will be receiving Healing Touch in person, and know that we will not be physical distancing during the session.* True False My temperature has not been above 100°F in the past 72 hrs.* True False I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks.* True False I acknowledge that I have not tested positive for COVID-19 nor have had COVID-19 within the last 20 days.* True False I have not had any of the following symptoms in the past 2 weeks: chills, cough, dizziness, loss of taste or smell, flu-like muscle aches or pain, Pink eye, shortness of breath, persistent chest pain or pressure, sore throat, COVID Toe (red patches on feet that look like frostbite).* True False In the event I contract Covid-19, I will notify my Healing Touch provider as soon as possible.* True False I acknowledge the contagious nature of COVID19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving Healing Touch and that such exposure or infection may result in personal injury, illness, permanent disability, and death.* True False I am fully vaccinated either with the Pfizer, Moderna, or Johnson and Johnson vaccine. ("Fully vaccinated" means 14 days after your J and J shot, or 14 days after a second shot of the Pfizer or Moderna vaccine.)* True False I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my Healing Touch appointment.* True False Δ
