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I knowingly and willingly consent to Therapy treatment for my child during the COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Although TLC has implemented protective measures at the clinic to mitigate the chances of contracting the COVID-19 virus, the risk still remains.

1. I confirm that I, nor my child, are presenting any of the following symptoms listed below:

• Fever
• Shortness of breath
• Dry Cough
• Runny Nose
• Sore Throat