covid 19 pre-appointment screening form

Please complete the following form and press the 'Submit' button within 24 hours of your appointment.

By submitting this form this is your declaration: I have understood, read and completed this form truthfully to my knowledge and consent to having the massage therapy treatment. I hereby release the business and the therapist performing the service  from any and all liability for any adverse reactions sustained as a result of the treatment, including unintentional exposure or harm due to Covid-19.

COVID 19 - Ongoing Screening Form
  • SYMPTOMS - Have you experienced any of the following in the last 7 days?:
    • High temperature or feeling feverish?:
    • Persistent cough or having breathing difficulties?:
    • Loss or change to sense of taste or smell?:
    • Cold-like symptoms such as headache, runny nose, sneezing or sore throat?:
    • VACCINATION - Have you had the Covid-19 Vaccination?:
    • VACCINATION: If you have had the Covid-19 Vaccination/s was your last vaccination more than 2 weeks ago?:
    • COVID-19: Are you considered at higher risk from Covid-19 (i.e. have a weakened immune system etc):
    • GENERAL HEALTH - Have you had any changes to your health - even minor changes - since your last massage appointment (if applicable)?:
    • COVID 19 - Have you had Covid-19?:
    • Date:
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    Calico Pregnancy Massage Covid 19 Form