ONE TIME WAIVER

COVID-19 RESOURCE, PROCEDURES and WAIVER FORM; This is a one time signing for business practice, standards and new policies per the State of NH and Governing Licensing Board:Covering; Bethany Chabot LMT, 444Hands Massage & Energy Therapy & Aesthetics by Alyssa Melanson All information protected by HIPPA.

YOUR HEALTH IS OUR NUMBER ONE PRIORITY.

COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/index.html

ACTION STEPS IN THE WELLNESS CENTER SIDE; 444Hands, & Aesthetics by Alyssa.

We are observing the following NH state guidelines for business operations in accordance with the state of NH Mandatory Guidelines https://www.nheconomy.com/whatsopen; Universal, Massage Therapy/Bodywork and Cosmetology and utilizing the Safer at Home practices and regulations found on NH.gov https://www.covidguidance.nh.gov/ and NHeconomy.com https://businesshelp.nheconomy.com/hc/en-us We will be holding ourselves accountable to the highest industries standards as always for not only our personal safety but yours as well. We thank you for your understanding and cooperation at this time to help keep us 100% compliant.

ONE TIME WAIVER AND PERMISSION/ LIABILITY FORM
Waiver Covers Massage Body Work & Energy Therapies and any additional services for operations under/ by any therapist operating out of 444Hands/Bethany Chabot LMT

These are the action steps you need to be aware of to observe on your next visit to see us. Please WAIT IN YOUR CAR, CALL OR TEXT US THAT YOU HAVE ARRIVED. IF we don’t answer right away we could be sanitizing and preparing the space for your session. We will be with you as soon as possible to meet you at the door to guide you through the new procedures to receive your treatment. NO WALK IN APPOINTMENTS, all clients must be scheduled prior and have passed their health screening, and all waivers, intake and any other new forms filled out via online platforms prior to scheduling/your scheduled appointment.

Please take a moment to read all of the following statements:

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to do Chiropractic adjustments, (sidenote the therapies used can lead to structural intergation and myoskeletal alignment cavitation adjustments), diagnose, prescribe drugs, or treat physical or mental illness.

I affirm that I have notified my therapist of all known medical conditions and injuries even if not listed on the first sheet.

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.

I understand that manual therapy and massage therapy is entirely therapeutic health care and non-sexual in nature.

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

I understand that should I cancel an appointment less than 24 hours before the scheduled time or “no show” an appointment, I am subject to a fee equal to the cost of the missed appointment. This fee is monetary. Please see cancleation policy at check out when booking online as well.

YOU MUST PASS YOUR HEATH SCREENING or we ask that you reschedule if need be based on the screening questions day of. Health Screening Questionnaire is to be filled out for each appointment and will be sent to you via text well in advance prior to your scheduled arrival. I understand that should I need to reschedule based on my daily health form I will also not be charged for a late cancel and will work with my practitioner to reschedule.

Y/ N*

If you are immunocompromised at any capacity please alert us as soon as you can so that we can reschedule your visit. This is a common courtesy that should be observed at all times.Y/N

Y/N*

You should be able to answer YES TO THE FOLLOWING:

As far as I know to be true I have been practicing social distancing and wearing masks when appropriate and have not come into contact with COVID that I am aware of.

Y/ N*

I will have a clean mask/ face covering designated for my treatment. Y/N*

I am willing to participate with all regulations to voluntarily seek treatments.

Initial to acknowledge your participation.*

I WILL alert you of any COVID positive results surrounding you/your household ASAP prior to or post any visit to us after 14 days of seeing us. YOU will be part of contact tracing list https://www.cdc.gov/coronavirus/2019ncov/php/openamerica/contact-tracing-resources.html should the need arise or if the state asks to provide them our screenings. We also will do the same should a positive result be revealed we will also alert you using the contact tracing list collected each day of operation.

Initial you read and understand the above information.*

PPE REQUIRED AT ALL TIMES; Face mask/covering https://www.cdc.gov/coronavirus/2019-ncov/downloads/clothfacecovering.pdf that goes over your mouth and nose to be used. Please have a clean washed or never been used mask for your treatment so the potential for contaminates on the mask are greatly reduced. We will also be masked with a new mask per client as well as a change of shirt for each client. We do ask that you limit the personal items you bring with you into your session leave it at home or in the car. We have special enclosed easily sanitized bags to hold your belongings in while in the treatment room. Gloves are being used when sanitizing by all practitioners. Gloves are required for all esthetics services at this time, we are also using a silicone based moose clear shield as an extra measure to aid in prevention of contamination.

Initial you read and understand the above information.*

HAND WASHING AND SANITIZING; These are basic hygiene standards that should be utilized every day, by everyone, every where. We ask you wash your hands prior to entering the treatment room as well post session to take the oils and creams from your hands so as not to transfer to your sensitive areas, ie eyes.

Initial you read and understand the above information.*

PLEASE NO OUTSIDE FOOD/DRINK of any kind including water bottles. we have also suspended our communal drink offerings at this time (tea station) we will have water bottles avail for emergency water needs.

Initial you read and understand the above information.*

We will be encouraging prepayments and online scheduling or scheduling via phone outside the time of your appointment. Should you need to pay with cash, please seal with tape or self adhesive envelope with your full name date of service on the outside of the envelope we cannot give change at this time.

Please contact your practitioner should you have further questions on specific scheduling needs.

Initial you read and understand the above information.*

All treatments and services to be paid in full once the service is completed.

PrintName*

Sign*

Signature*

Date:*

Date

Initial you read and understand the above information.*

Your Initials