Forms

Health Information–COVID-19 Information & Liability Waiver

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. In addition, signing this form prior to each appointment in now required. Please complete the following within 24 hours of your appointment and sign below.

Have you had a fever in the last 24 hours of 100°F or above? *

Yes No

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *

Yes No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Yes No

Consent for Treatment I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

* Indicates required field

Date *

Name *

First

Last

Email *

Submit