The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions of which Trinity and Company, adheres to comply, along with increased sanitation and disinfecting practices within our facility. Please complete the following checklist and sign below.
I confirm that I. including members within my household, have not experienced any of the following symptoms within the last 14 days:
Headache New loss of taste or smell Sore throat
Congestion or runny nose Nausea or vomiting
To the best of my knowledge I, including all members within my household, have not recently tested positive, or been in contact with anyone who has tested positive for COVID-19 within the last 14 days. (initial)
I verify that I, including all members within my household, have not traveled internationally in the past (initial) 30 days.
Due to the nature of the service/treatment/procedurel will be receiving today, I understand that social distancing of at least 6 feet, as recommended by the CDC, is not possible. (initial)
I am fully and personally responsible for my own safety and actions during my service/treatment/procedure, and I recognize that may be in any case at risk of contracting COVID-19. (initial)
Iagree to hold Trinity and Company]. not liable for any and all cost, expenses, damages, lawsuits and/or liabilities that may arise from direct, indirect, or in relation to any and all claims made by or against any of the released party due to injury. loss, or death from or related to COVID-19. (initial)
By signing this form, I certify that I have been given the opportunity to ask any questions I may have, and those questions have been answered I acknowledge I have read and fully understand the contents of this waiver, and I have been sufficiently informed of the risks involved. I certify am at least 18 years of age, and fully competent to give my consent. I agree to hold Trinity and Company, harmless from any and all liability for the unintentional exposure, harm, damages, or risks involved due to COVID-19.