COVID-19 Forms | Jessie Duncan Wex, LMT

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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

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 received all doses of the COVID-19 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.

Fully vaccinated clients may take their face covering off for short periods of time during massage when having their jaw manipulated, or when face down in the face cradle.

Thanks for submitting!

Massage Intake

Covid-19 Health Declaration