Informed Consent & COVID-19 Liability Release Form

375 Bay Road Suite 104 Queensbury, NY 12804

518-615-4622
Informed Consent for Any Virus/Flu/COVID-19 Liability Release Form

***PLEASE Fill Out 24 hours BEFORE coming in for your appointment to AVOID cancellation of your scheduled appointment***
Name*

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Email Address**PLEASE NOTE, you MUST Re-Enter your Email Address to submit the form***

Confirmation Emailexample@example.com
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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 Any Virus/Flu/COVID-19. By initialing and signing this form, I ACKNOWLEDGE that I am AWARE of the RISKS involved and knowingly and willingly CONSENT to receive a massage therapy session at Graceful Touch Massage Therapy even though I am NOT 100% PROTECTED from Any virus/Flu/COVID-19 which may cause extreme sickness or death. I ACCEPT the risks and ALL responsibility in the event I test positive following my massage therapy session.*
PLEASE Initial in the Box.
To PREVENT the spread of contagious viruses and to HELP protect each other, I UNDERSTAND and WILL follow this office's policies and procedures (washing my hands, removing my shoes, temperature and oxygen levels taken, etc.) that were sent to me via text/ email.*
PLEASE Initial in the Box.
I UNDERSTAND Any virus/Flu/COVID-19 has a LONG incubation period during which the carrier of the virus MAY NOT show symptoms or be asymptomatic and still be HIGHLY contagious.*
PLEASE Initial in the Box.
I UNDERSTAND that air travel increases the risk of contracting and transmitting Any virus/Flu/COVID-19. I AFFIRM that I am monitoring for symptoms and WILL notify my therapist, Grace McDonald, IF I do not feel well the day before OR the day of my appointment to reschedule my appointment.*
PLEASE Initial in the Box.
I AFFIRM that I, as well as ALL household members HAVE NOT been diagnosed Any Virus/Flu/COVID-19 in the last 10 days. IF I or anyone in my household was ANY VIRUS /FLU/COVID-19 POSITIVE, I WILL test 2 days BEFORE my scheduled appointment and reschedule for the safety of my massage therapist, Grace McDonald and other clients, should I receive a POSITIVE result.*
PLEASE Initial in the Box.
I UNDERSTAND that Graceful Touch Massage Therapy and my massage therapist (Grace McDonald) CANNOT be held liable for any exposure to ANY Virus contagion caused by misinformation on this form OR the medical history provided by me as a client of Graceful Touch Massage Therapy.*
PLEASE Initial in the Box.
I UNDERSTAND that a client or Grace, my massage therapist, at Graceful Touch Massage Therapy MAY test positive for Any Virus/Flu/COVID-19. I give my CONSENT for Grace to contact me to inform me of this development.*
PLEASE Initial in the Box.
I CONFIRM that I AM NOT presenting ANY of the following symptoms of Any Virus/Flu/COVID-19 BELOW and I AM WILLING to have my temperature taken BEFORE the start of my session. IF I have a temperature of 100.4 and ABOVE, I WILL reschedule my session.*
PLEASE Initial in the Box AFTER you've read the symptoms BELOW.
I AM NOT presenting ANY of the following symptoms of Any Virus/Flu/COVID-19 BELOW:
- Fever in the last 24 hours of 100.4 or above
- Shortness of breath OR difficulty breathing
- Sore throat
- Dry cough
- Runny nose
- COVID toes (Painful red or purple lesions on toe/toes)
- Unusual fatigue
- Body Aches
- New rash or other changes to my skin
- Unusually painful muscle aches that I feel massage may help OR cramping in my lower leg
Graceful Touch Massage Therapy ABIDES by the standards on this form. I,(Grace McDonald) also AFFIRM that I have improved and expanded my already HIGH disinfection protocols to more throughly fight the spread of Any Virus/Flu/COVID-19 and other communicable conditions.
By signing below, I AGREE to each above statement. I VOLUNTARILY AGREE to assume the RISKS and RELEASE and hold harmless my massage therapist (Grace McDonald) and Graceful Touch Massage Therapy from ANY and ALL liability or any claims related thereto for the unintentional exposure or harm due to Any Virus/Flu/COVID-19. I GIVE MY CONSENT to receive my massage therapy session and UNDERSTAND that I am choosing a service that is not medically necessary. I also UNDERSTAND that I am NOT 100% PROTECTED from Any Virus/Flu/COVID-19 which may cause extreme sickness or death. I am responsible to notify my massage therapist, Grace McDonald, and Graceful Touch Massage Therapy of any changes in the above statements, or if my family members develop symptoms or are diagnosed with Any Virus/Flu/COVID-19 5 days before OR 5 days after my appointment.
PLEASE Sign in the Box Below.*

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375 Bay Road Suite 104 Queensbury, NY 12804

Informed Consent for Any Virus/Flu/COVID-19 Liability Release Form