Please scroll down for the Swedish/Deep Tissue Massage Health Intake form.
I will be carefully monitoring my health and those in my household to make sure no one is exhibiting any symptoms of COVID-19 including, but not limited to, fever of 100 or greater, cough, shortness of breath, etc. If so, I will cancel all clients and quarantine for 14 days or 7 followed by a negative COVID-19 test.
I will cancel sessions if I am in contact with anyone who tests positive for COVID-19 and quarantine for 14 days or 7 days followed by a negative COVID-19 test.
I will not travel to any counties that have greater the 400 active cases per million of COVID-19. If for some reason I have to travel to a county with greater then 400/million cases I will quarantine for 14 days or 7 days followed by a negative COVID-19 test before seeing clients. I will inform clients ahead of time if I do need to travel and will need to cancel any scheduled appointments.
I will always wear a mask in my space.
I will leave the necessary time between clients to properly clean and disinfect my space based on the CDC guidelines. This includes, but is not limited to, door handles, phones, pens, tables, face rest, chairs, and any other high touch surfaces.
Hand sanitizer will always be available to use. I will sanitize my hands immediately before starting a session.
I have a ventilation system going at all times as well as a HEPA filter.
The 24-hour cancellation fee will be waived for any issues or concerns due to COVID-19.
The ACCD requires customers' names and contact information to be logged for 30 days. This information will be shared with the Health Department if needed for contact tracing.
Consent for Treatment
To proceed with receiving care, I confirm and understand the following.
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a small space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge the increased risk of infection of COVID-19 from sustained close contact within a small confined space and I give my informed consent to receive a massage from Genevieve Henry under these conditions.
I understand that COVID-19 has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand that COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I promise to be carefully monitoring my health and those in my household to make sure no one is exhibiting any symptoms of COVID-19 including, but not limited to, fever of 100 or greater, cough, shortness of breath, etc. If so, I will cancel my appointment and reschedule after 14 days in quarantine or 7 days followed by a negative COVID-19 test.
I will cancel my appointment if I have been in contact with anyone who tests positive for COVID-19 and will wait to reschedule until I have finished 14 days in quarantine or 7 days followed by a negative COVID-19 test.
I will cancel my appointment if have traveled to a county with higher then 400 active cases per million of COVID-19 or have traveled by bus, train or airplane within 2 weeks of my appointment. I will not reschedule until I have finished 14 days in quarantine or 7 days followed by a negative COVID-19 test.
I understand that my practitioner will participate in contact tracing if necessary and that in such an instance my name and contact information may be shared with state agencies.
I understand that should I, within 14 days of my appointment, test positive for COVID-19, experience COVID-like symptoms, or learn that I was previously exposed to someone else with COVID-19 symptoms, I will contact Genevieve Henry immediately with this information.
I will wear a mask at all times during my appointment (a face cradle hammock may replace a mask in the prone position if necessary for client comfort).
Protocol when coming to the office for a session:
When you arrive at the office please wait in your vehicle or outside and call or text to let me know that you have arrived (not more than 5-10 mins before your scheduled appointment). My cell phone is 802-373-3236.
A face mask is required upon entering the office building and will need to remain on throughout the session.
I will be using a no-contact thermometer when you arrive to assess your temperature and make sure it does not exceed 100.4 F
I will ask you to please wash your hands with soap and water before our session.