Consent Form for COVID-19

Confidential Client History Form

An accurate health history ensures that it is safe for you to receive a massage treatment, and helps the therapist determine a proper treatment plan. Should your health status change in the future, please let us know.

All information gathered on this form is confidential. Your written authorization is legally required before any of this information can be released.

Personal Information

    Name (first/last)


    Email address
    As per Canada’s Anti-Spam Legislation (CASL) I consent to receiving electronic messages for promotions and periodic updates only, to the email address above:
    YesNo


    Contact Phone#


    COVID-19 Precautions

    I confirm that I am NOT presenting any of the following symptoms of COVID-19 identified by Alberta Health Services

    • Fever > 38° C
    • Cough
    • Sore Throat
    • Runny Nose
    • Shortness of Breath
    • Difficulty Breathing
    • Flu-like Symptoms
    • Loss of Smell/Taste

    I confirm that

    • I am NOT currently positive for the COVID-19 Coronavirus.
    • I am NOT waiting for the results of a laboratory test for the COVID-19 Coronavirus.
    • I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the COVID-19 Coronavirus. Alberta Health Services require self-isolation for 14 days from the date a person has returned to Canada. I verify that I have NOT returned to Alberta from any country outside of Canada whether by car, air, bus or train in the past 14 days.
    • I verify that I have not been identified as a contact of someone who has tested positive for the COVID-19 Coronavirus or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.
    • I confirm that the information I have provided on this form is truthful and accurate. I understand that Euphoria Wellness Centre, their massage therapists and their staff are taking precautions to limit any potential exposure to the COVID-19 Coronavirus. I also understand that there are inherent risks with massage therapy and acupuncture. I knowingly and willingly consent to have massage/acupuncture treatment performed at Euphoria Wellness Centre during the COVID-19 pandemic.




    Client Signature:
    Date:


    Parent/Guardian Signature (if client under 18 years of age)