Health Intake, COVID-19 information, Liability, Waiver, and Informed Consent

Client Name: Date:

According to the local COVID-19 standards, I will be wearing a mask and ask you to as well.  In addition to my regular cleaning regimen, I will be cleaning my office after every client with an EPA approved cleaner.  

Covid-19 Information

1. Have you had a fever in the last 24 hours of 100 degrees F or above?

2. Do you now or have you recently had any respiratory or flu symptoms, sore throat, rashes, chills, muscle aches, loss of taste, loss of smell, skin lesions, or shortness of breath?

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with Covid-19 or has coronavirus symptoms?

4. Have you traveled outside the US in the past 14 days? By airline, bus, or train? 

5. Have you traveled outside the state of NC?

6. Have you been in large crowds without safe practices?

7. If you become aware that you have COVID-19, please inform me (as I will as well).

Informed Consent for Treatment

I understand that because massage therapy work involves maintained touch and close physical proximity over an extended period, 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, Joslyn Strickland.

Client Signature: Date:

Therapist Signature: Date: