Better Bodies Massage COVID19 Screening FormPlease fill out the form below before attending your appointment. Name * First Name Last Name Email * Phone * Appointment Date * MM DD YYYY Date of Birth * MM DD YYYY Emergency Contact * Emergency Contact Number * Have you been fully vaccinated against COVID19? * Yes No first dose only If Vaccinated, was your last dose administered in the past 2 weeks? * Yes No If you answered YES above, Are you experiencing any side effects still from the vaccine? please describe below Please indicate if you are currently experiencing any of the following symptoms: Fever Dry cough or sore throat Runny nose Unexplained muscle or joint pain Headache Excessive tiredness Shortness of breath Loss of smell/taste Upset stomach/diarrhoea Loss of appetite None of the above Are you or any of your close contacts and household members awaiting results of a COVID-19 test or been confirmed positive for COVID-19? * Yes No Yes regular surveillance testing result only Have you been identified as a close contact or do you live with someone who has been advised to self isolate? Yes No I understand that because massage involves touch and close physical proximity over an extended period of time there may be an elevated risk of disease transmission, including COVID-19. I also understand that even if an individual has received a vaccination against COVID-19 that they may still contract and transmit the virus to other individuals. The therapist has explained the risks to me and I consent to receive massage. I consent to having my contact information shared with the relevant government authorities in the event that contact tracing is required. * I agree and consent to the above. Thank you!I am looking forward to seeing you soon.Please read my Covid Safe Plan for further information.
