2020/21 ONE TIME WAIVER

2020/21 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.

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.

Initial you read and understand the above information. *

Your Initials

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 cancle and will work with my practitioner to reschedule.

Y/ N *

If you are sick for any reason please alert me as soon as you can as you must 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 will guide you to the wash station to wash your hands prior to entering the treatment room as well as prior to your exit. We have several hand sanitizers avail for your use in the building as well. Please Observe the proper hand washing techniques.

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. *

Note we are operating with longer time between clients and potential different hours of operation to allow for us to continue to operate at our already high level of industry standards but to insure the extra measures with the guides linked above. We have a checklist for communication between the three businesses working with in our Wellness Center Side of the building. We have also closed off the partition door and are not cross contaminating with Family Chiropractic of Merrimack. Please note you will not be allowed to walk through the internal door for Chiropractic services and encourage you to seek use of their main door and observe the UNIVERSAL GUIDES when visiting them including but not limited to washing your hands on entry and mask wearing when receiving your adjustment. Thank you.

Waiver and Consent for TREATMENT: You will need to sign this as your waiver form one time and your health screening similar to that above for each visit, every time you see us a new screening is required. By accepting a treatment slot you agree to uphold all regulations set forth by the State of NH Governor, The Department of Health and Human Services (DHHS), and The Department of Business and Economic Affairs (BEA) in accordance with CDC and OSHA. COVID- 19 is a highly contagious virus that spreads easily from person to person. That said these best practices still offer no guarantee regarding the potential risk of being infected. I understand that due to the nature of the intimate physical close proximity and extended period of time with treatment services for self care there may be an elevated risk involved from receiving treatment at this time. I voluntarily agree to assume those risks and Release/Waive any and all liabilities of my practitioner/business from claims related thereto. I consent to treatment with new regulations and have honestly answered my health screening to what I know to be true. I consent to documentation of my visit for a contact tracing list should the need arise for a contagion tracking per any request from the state, hospital or other.

I had read and acknowledge this information and will comply with signing all required documentation to be eligible for services.

PrintName *

Sign *

Date: *

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