Covid 19 Check

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COVID-19 Guidelines

Please be advised of the policies for this office.

Cancellation

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients. we hope this will alleviate any stress and hesitation you have about an upcoming appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request for you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for cancellations at this time.

Tardiness
Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment.

Sickness
Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition.

Please complete fully

* Indicates required field

Name *

First

Last

Email *

Date *

COVID-19 Information

1. Have you had a fever in the last 24 hours of 100(degree sign)F or above? *

Yes No

2. Have you had a fever in the last 14 days of 100(degree sign)F or above? *

Yes No

3. Do you now or have you in the last 14 days had any respiratory or flu symptoms, sore throat or shortness of breath? *

Yes No

4. Do you now or have you in the last 14 days had any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *

Yes No

5. 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

Do you have special needs I should prepare for: *

Do you have any questions or concerns: *

Consent for Treatment

I understand that, because massage therapy work 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. By coming into Salina Massage Therapy, I acknowledge that I am aware of the risks involved from receiving treatment at this time. I voluntarily agree to assume those risks.

My submission of this form gives my consent to receive treatment from Carol Rubino and Joe Rubino and holds harmless Carol Rubino, Joe Rubino and the business of Salina Massage Therapy from any claims related thereto.

Signature/name *

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Salina Massage Therapy
429 N. Ohio Street, Suite 2
Salina, KS 67401
info@salinamassagetherapy.com
1-785-819-4392

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