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5252 Lyngate Court Suite 202

Burke, Va. 22015

571-217-1150

info@serendipitywellnessstudio.com

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Save time- complete your new client intake forms ahead of time.

Covid-19 Health Declaration

First Name

Last Name

Appointment Date

Email

Have you had a fever in the last 24 hours of 100°F or above?

YES

NO

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?

YES

NO

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?

YES

NO

Can you exercise to get your heart rate and respiratory rate up without any problem? (This would indicate whether their cardiopulmonary function is unimpaired.)

YES

NO

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

YES

NO

Have you had a new onset of muscle aches and pain since the emergence of the virus? (This is a possible early sign of coagulopathy, and a reason to defer treatment until you have been tested and cleared of coagulopathy risk.)

YES

NO

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin? (This indicates the possibility of microvascular clotting, and is reason to defer treatment until you have been tested and cleared of coagulopathy risk.)

YES

NO

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.

I knowingly and willingly consent to the treatment with the full understanding and disclosure of the risks associate with receiving care during the COVID19 pandemic. I have read the above COVID 19 risk informed consent to treat. I appreciate that it is not possible to consider every possible complication to care. I understand that, because massage therapy/esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19

I declare that the info I’ve provided is accurate & complete

Initials

Date

Thanks for submitting your COVID form!

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