Benicia Wellness Center COVID-19 Massage Form

COVID-19 Informed Consent Benicia Wellness Center is committed to maintaining your health & safety. However, your risk of infection from coronavirus (the disease that causes COVID-19) increases through close contact with other people, like the level of contact required to provide a massage.

In order to protect your health and the health of our employees, our practice follows Practice Guidelines recommended by the ​Federation of State Massage Therapy Boards​ (FSMTB), along with infection control recommendations made by the U.S. ​Centers for Disease Control and Prevention​ (CDC) and the ​Occupational Safety and Health Administration​ (OSHA). We are remaining vigilant in our efforts to protect your health, and we’re happy to provide you with a comprehensive list of our new COVID-19 Operation Procedures at your request.

In the event that someone who works for or received treatment from Benicia Wellness Center tests positive for COVID-19, we will provide the Health Department with whatever information they require to track & trace coronavirus transmission. This may mean that your name and contact information is shared with health officials. The ​Health Insurance Portability and Accountability Act​ (HIPAA) makes a specific exception for health emergencies, meaning that your permission is not required before we share your relevant information with the state & local health departments.

Before receiving a massage at Benicia Wellness Center, we need you to affirm the following (​please initial​):

_________​I understand that close contact with people increases the risk of infection from COVID-19. By initialing this line and signing below, I acknowledge that I am aware of the risks involved and give consent to receive a massage from my practitioner.

_________​I understand that my name and contact information might be shared with the state health department in the event that a patient or practitioner at this office tests positive for COVID-19. My contact details will only be shared in the event that they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

I, <FIRST NAME> <LAST NAME>, have been informed and understand the new risks of receiving massage therapy while COVID-19 is present in our community. I also understand that in the event a positive COVID-19 case is associated with Benicia Wellness Center, my personal information might be shared with public health officials in their efforts to maintain public safety. By signing below, I consent to receive massage therapy from my practitioner.

__________________________________________ <TODAY> <FIRST NAME> <LAST NAME>

COVID-19 Health Screening To best protect your health and the health of others, please fill out this form before each massage. We appreciate your cooperation.

NAME: <FIRST NAME> <LAST NAME> DATE: <TODAY>

Have you been tested for COVID-19?

Y / N

What is the date of your most recent test? ​____ /____ /____​ What were the results? ​+ / -

Have you been in places with a high infection rate within the last two weeks (e.g., state-designated “hotspots”)? If yes, please explain verbally to your practitioner.

Y / N

Please check if you are experiencing any of the following as a NEW PATTERN in the last 14 days:

___ ​Fever ___ ​Chills

___ ​Sore throat

___ ​Diarrhea, digestive upset ___ ​Nasal/sinus congestion ___ ​Loss of taste or smell ___ ​Fatigue

___ ​Shortness of breath

___ ​Sudden onset of muscle soreness (not related to a specific activity) ___ ​Rash or skin lesions (especially on the feet.

I declare that the information provided above is true and accurate to the best of my knowledge.

________________________________________ <TODAY> <FIRST NAME> <LAST NAME>