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Intake Form

To best protect your health and the health of others, please answers this questions before each massage and bodywork session.

1. Have you tested positive for COVID-19?

2. Do you experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:

- Fever
- Chills
- Cough
- Sore throat
- Diarrhea
- Digestive upset
- Nasal, sinus congestion
- Loss of sense 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)
3. Do you have any new discomfort with exertion or exercise?

4. Are you taking any medications that may be a contraindication to massage?

5. Do you have any allergies?

If your answer is YES to any of these questions, I need to reschedule you to see the doctor so he/she can check you. Our health is the priority. We both must be healthy both before & after the sessions.


Thank you.


What did I do to keep you safe?

1. Routine cleaning.
2. Disinfect surfaces by applying an EPA-registered disinfectant to the surface
3. Ventilating the space by opening doors and windows and by running fans to reduce the airborne presence of cleaning chemicals.
4. Make alcohol-based hand sanitizer easily accessible to clients entering the facility and encourage clients to sanitize their hands upon arrival.
5. Make tissues and no-touch trash cans available for the practice of respiratory hygiene and cough etiquette.
6. Encourage clients to wear their own face mask to the facility. Provide surgical or other disposable face masks to those without a face covering upon arrival.
7. Install HEPA air filtration systems to improve the quality of the air.
8. Clean floors at the end of the day by mopping hard floors with an EPA-registered floor cleaner. Vacuum carpeted floors using a vacuum cleaner.
9. Deep clean the restroom at the end of the workday by cleaning the toilet bowl, toilet seat, the toilet lid, the walls around the toilet, and all surfaces with appropriate cleaning products and an EPA-registered disinfectant.
10. Ventilate restrooms overnight by opening doors and windows or running a HEPA air filtration unit in the area.
11. Cover the massage table or the warmer and padding on the massage table with a heavy-duty plastic sheet or table protector. Disinfect the plastic sheet over the massage table with an EPA-registered disinfectant between clients.
12. Prepare the massage table with clean linens.
13. Typically, linens are stored in a ventilated container in the laundry area. While COVID-19 is present in a community, store linens in a closed container.
14. Wash soiled linens with detergent in hot water and dry it completely using heat. Wash linens promptly (by the end of the workday).
15. Followed CDC guidelines and Federation of state massage therapy boards (FSMTB).


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