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COVID Information & Consent
INFORMED CONSENT I understand that COVID-19 is highly contagious and still
present in the community where I am seeking massage therapy. I understand that COVID-19 is passed through close contact with
others and that people without symptoms may be infectious. I understand that this massage business has taken every precaution
to ensure my health and safety but that risk of infection is still possible. _________________________________________________________________________
(Signature and Date) HIGH RISK AWARENESS I understand that the heath conditions listed on page 2 of this document place me or my dependent at higher risk
for serious illness from COVID-19 infection. If I have one of these conditions I or my dependent should forgo massage therapy
while COVID-19 is still present in my community, or obtain my physician's consent to receive massage therapy. Should I or
my dependent decide to proceed with massage therapy I assume all risk related to illness from COVID-19 infection. _________________________________________________________________________
(Signature and Date) DEPARTMENT OF HEALTH
AND EXPOSURE TO COVID-19 I understand that in the event that a client, therapist, or staff member of this facility
tests positive for COVID-19 within a time period that places me at risk of exposure, my name and contact information will
be shared with the State Department of Health for their follow-up. In the event that I develop symptoms of illness within
two weeks of my massage appointment, I will contact this massage facility immediately. _________________________________________________________________________
(Signature and Date) According to the Centers for Disease Control
and Prevention (CDC), people of any age with these underlying health conditions are at increased risk for developing severe
illness from COVID-19. |
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