COVID-19 has been declared a worldwide pandemic by the World Health Organization and is believed to spread mainly from person-to-person contact. To prevent the spread of COVID-19, our practice has state-mandated precautions and sanitation practices in place (as noted in our e-newsletters, appointment reminder emails, and office signage), aimed at reducing/ eliminating unnecessary contact and providing equal protection for both you (client) and us (staff & practitioners). Please complete and submit this form no earlier than 12 hours before your next massage therapy appointment. Thank you!
Your cell phone number (so we can text/call you when you arrive)
What day and time is your scheduled appointment?
Have you ever been diagnosed with COVID-19?
If yes, when?
By placing a check-mark over the square before each statement below, you (the client) agree to abide by the following:
Prior to my appointment, I will wait in my vehicle until I receive a text or call from my practitioner indicating when to enter the building.
I have been practicing social distancing to the best of my ability.
I agree to have my temperature taken upon arrival.
I will wear a face covering at all times while in the building, except in the prone (face down) position on the massage table.
I (and my household members) have NOT had a cough, sore throat, runny nose, or fever within the last 14 days, nor am I currently on antihistamines to cover these symptoms.
I (and my household members) have NOT traveled internationally or to any high-risk regions affected by COVID19, visited a nursing home, or been knowingly exposed to or in contact with anyone diagnosed with COVID-19 within the last 14 days.
If I am “high risk” for a poor response to COVID-19, I am aware of the risk factors associated with hands-on contact with my massage therapist. "High risk” includes (but is not limited to) those 65+ years of age, history of diabetes, high blood pressure, heart disease, stroke, respiratory issues, or those with compromised immunity).
I acknowledge that B In Touch Massage Therapy, as well as any of its employees or independent contractors (including but not limited to my massage therapist) cannot beheld liable for any exposure to COVID-19 I may receive before, during, or after receiving massage therapy treatment from B In Touch Massage Therapy. By signing below, I voluntarily agree to this statement and release B In Touch Massage Therapy from any liability for any unintentional exposure or harm arising from COVID-19.
I acknowledge that my massage therapist and staff at B In Touch Massage Therapy have the right to decline treating me if I have a fever, am unable or unwilling to check off any of the above statements, or if they otherwise feel uncomfortable proceeding with treatment.
I acknowledge that this waiver was completed within 12 hours of my associated appointment at B In Touch Massage Therapy.
Signature (use your mouse or finger to sign)
Should be Empty: