Precautionary Coronavirus Liability Release Form

 

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below

 

1, Fever

2,Fatigue

3, Dry Cough

4,Difficulty Breathing

 

I, ____________________________ agree to the following

 

 

  • I understand the above symptoms and affirm that I, as well as all household members do not currently have, nor have experienced the symptoms listed above within the last 14days.

  • I affirm that I as well as all household members, have not been diagnosed with COVID19 within the last 30days.

 ○I affirm that I ,as well as all the household members, have    not knowingly been exposed to anyone diagnosed with     COVID-19 within the last 30days.

  • I affirm that I ,as well as all the household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a "hotspot" forCOVID-19 infections within the last 30days.

  • I understand that this business and my therapist cannot be held liable for any exposure to the virus or any other contagion caused by mis information on this form or the health history provided by each client

 

By signing below, I agree to each above statement and release the therapist and business from any and all liability and for the unintentional exposure or harm due to COVID-19. Your therapist and all team members of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

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