Being Responsible in Challenging Times

Wholesome Healing is doing their part to ensure the safety and security of my clients and myself. Please review the following information below and fill out the short questionnaire. Thank you for your business and being part of the solution.

COVID-19 Protocol

The following is a list of my protocol for both clients and therapist. After reading this information, please fill out the questionnaire below:

Clients:

✓ Send text upon arrival
✓ Answer screening questionnaire
✓ Sign consent
✓ Wear mask
✓ Allow temperature check
✓ Wash hands
✓ Wipe down phone/tablet
✓ Option to stay fully clothed for session

Therapist:

✓ Provide screening questionnaire
✓ Check client temperature
✓ Provide mask for client
✓ Provide wipe for phone cleaning
✓ Wear mask, apron, and eye protection
✓ Wash hands
✓ Wear gloves if client prefers
✓ Run HEPA air purifier
✓ Clean treatment room thoroughly after every session

It is difficult to say what is impossible, for the dream of yesterday is the hope of today and the reality of tomorrow.

Contact Us

Name
First Last
Email
Do you have a cough, shortness of breath, or are you having difficulty breathing?*
- Yes
- No
Have you experienced any of these symptoms in the past 7 days: fever, chills, headache, diarrhea, vomiting, muscle pain, sore throat, or new loss of taste or smell?*
- Yes
- No
Have you tested positive for COVID-19 or have you been around anyone with known or suspected COVID-19 in the past 14 days?*
- Yes
- No
Have you traveled in a region with significant COVID-19 community spread in the past 14 days?*
- Yes
- No
Consent
I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner. I also understand that my name and contact information might be shared with the state health department in the event that a client or therapist at Wholesome Healing, Inc. tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.
Date
MM slash DD slash YYYY

Being Responsible in Challenging Times

Wholesome Healing is doing their part to ensure the safety and security of my clients and myself. Please review the following information below and fill out the short questionnaire. Thank you for your business and being part of the solution.

It is difficult to say what is impossible, for the dream of yesterday is the hope of today and the reality of tomorrow.

Contact Us

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