COVID-19 Forms | Jessie Duncan Wex, LMT

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat, runny nose

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Niether myself, nor anyone that I live with, has tested positive for COVID-19 in the past 14 days

I have been vaccinated in the past 6 months or received a COVID-19 booster vaccine.

Initials

Date

I declare that the information I’ve provided is accurate & complete. I understand the ever changing nature of COVID information and promise to educate myself on the proper precautions I must take to lower my risk of spreading the virus.

I understand that the World Health Organization has declared the novel Coronavirus a global pandemic and that it is extremely contagious. Despite increased sanitation and extra precautions, it is possible to contract COVID-19 through person-to-person contact in an enclosed space for 75 minutes. I hereby assume that risk and give Jessie Duncan Wex, LMT express permission to procede with providing care.

I agree to wear either two masks or an N95 or KN95 mask for the entire session.

Thanks for submitting!

JESSIE DUNCAN WEX, LMT

Massage Intake

Covid-19 Health Declaration