105 N Mansfield Ave, Margate, NJ | 609-350-0751
Effective June 20, 2020
Please fill out & submit this form the morning of EACH appointment.
Respiratory intake form for Reiki Therapy
For all of our safety, please fill this out within 24 hours of your Reiki session - preferably the morning of your Reiki session (for each Reiki session until further notice). Be sure that the information you give is honest, accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
I agree to the following:
I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days.
I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.
In the past 14 days, I have experienced...
Fever of 100.4°F +
Unexplained body aches or pain
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Non-allergy related runny nose
Informed Consent for Prolonged Exposure
I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive Reiki Therapy from Melanie Zappone at Downbeach Reiki. I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.I further acknowledge that Downbeach Reiki has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.I further acknowledge that Downbeach Reiki can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families. I voluntarily seek services provided by Downbeach Reiki and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.I attest that:* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.* I have not traveled internationally within the last 14 days.* I have not traveled to a highly impacted area within the United States of America in the last 14 days.* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Melanie Zappone at Downbeach Reiki harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the business, or that may otherwise arise in any way in connection with any services received from Downbeach Reiki. I understand that this release discharges Melanie Zappone at Downbeach Reiki from any liability or claim that I, my heirs, or any personal representatives may have against the business with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Downbeach Reiki. This liability waiver and release extends to the Downbeach Reiki together with all owners, partners, and occupants.
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm