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COVID Information & Consent

Signature Required

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. 

  • People 65 years or older
  • Children who are medically complex with underlying health conditions
  • Women who are pregnant
  • People with neurologic conditions (e.g., dementia)
  • People with chronic obstructive pulmonary disease
  • People with pulmonary fibrosis
  • People with moderate to severe asthma
  • People with cystic fibrosis
  • People with serious heart conditions
  • People with hypertension (high blood pressure)
  • People with sickle cell disease
  • People with thalassemia (a type of blood disorder)
  • People with cerebrovacular disease (affects blood vessels and blood supply to the brain)
  • People undergoing cancer treatment
  • Bone marrow or organ transplant recipients
  • People with immune deficiencies from medications or use of corticosteroids
  • People with HIV/AIDS
  • People with obesity (BMI 30 or higher)
  • People with diabetes (type 1 and type 2)
  • People with chronic kidney disease and undergoing dialysis
  • People with liver disease People who are smokers