COVID FORM | TruMassageTherapy

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 and do not have chills

I am not experiencing the symptoms: fever, cough, sore throat, loss of taste/smell

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

Initials

Date

I declare that the info I’ve provided is accurate & complete & promise to do my part to keep others safe. (We have a thermometer on the wall in our lobby).

Thanks for submitting within 24 hours of your scheduled appointment. This is just the Covid pre office health screening. This does not count as scheduling appt (make sure you have a scheduled appt within the next 24 hours first). If you are a new client please save then fill out the new client pdf on our home page and email to

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Covid-19 Health Declaration