Please be advised of the policies for this office. Your choice to book an appointment signifies acceptance of these policies. You will be expected to sign this form at the time of your appointment. It will be kept on file with all confidential client information.
COVID-19 Information & Liability Waiver
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.
I understand that COVID-19 is a new illness and research developments and understanding is ongoing. I understand that office policies and massage treatments may change or be altered with short notice.
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.
Case Investigation & Contact Tracing
I understand that case investigation and contact tracing is a disease control measure employed by the local and state health department to prevent further spread of COVID-19. I understand that my contact information may be requested by and provided to Public Health Staff if I have been identified as someone who is at risk of exposure to COVID-19. This action will help me to protect my friends, family, community members and future contacts from future potential infections.
A note on contact tracing: To protect client and patient privacy, contacts are only informed that they may have been exposed to a patient with the infection. They are not told the identity of the patient who may have exposed them.
If I become ill with COVID-19 within 14 days of my appointment I agree to contact Eden Therapeutic Massage to notify them of the chance of exposure. If I notify Eden Therapeutic Massage I understand that my name, contact information, and potential exposure status will be kept strictly confidential.
Client Name: ______________________________________
1. Have you had a fever in the last 24 hours of 100°F or above?
Yes ☐ No ☐
2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
Yes ☐ No ☐
3. 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 ☐
Client Signature: _________________________________________________
Parent or Guardian Signature (in case of a minor): _______________________