Covid-19 Information and Liability Waiver

Covid-19 Information and Liability Waiver

For Rebecca Brancheau Massage and Creekside Wellness Center
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Please Select a "No" or "Yes" answer:
Have you had a fever of 100F or above in the last 24 hours?

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

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

NoYes
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.
Signature

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