Clients must be willing to provide this information and sign each time they arrive for their massage
COVID-19 KNOWN RISK CONSENT FORM & WAIVER OF LIABILITY
This is an informed consent document, which has been prepared to help inform you about your Elective Treatment with respect to COVID 19. There are known increased risks of contracting COVID-19 associated with services requiring close proximity to other individuals, including, but not limited to, massage services. It is important that you read this information carefully and completely and fill in the requested information completely and truthfully. Upon completion, please sign below, indicating your affirmation of the statements you have made on this consent form, your understanding, acknowledgement, and consent to the risks described herein, and your authorization for us to perform your elective treatment during the current COVID-19 epidemic.
Name: ________________________________________ Date of Birth:_______________
QUESTIONNAIRE
In the past 14 days, have you or anyone in your household had:
❒ Fever greater than 100.3 Fahrenheit
❒ Acute respiratory symptoms such as cough, shortness of breath, sore throat
❒ Physical symptoms such as body aches or chills
❒ A recommendation to remain in isolation
❒ A Covid-19 diagnosis
❒ Recent travel to a known “hot spot” for COVID-19
❒ Recent international travel
❒ Close contact with anyone with a confirmed Covid-19 diagnosis
❒ Close contact with anyone who has travelled internationally
❒ Close contact with anyone who has travelled to a known “hot spot” for Covid-19
❒ Close contact with anyone who has travelled to a known “hot spot” for Covid-19
Do you now or have you ever had:
❒ History of coagulopathy (a condition in which the body’s ability to form blood clots is impaired)
❒ History of pulmonary embolism, cardiac embolism, or brain embolism
❒ A prescription or recommendation by a physician to take blood thinners
RISKS AND COMPLICATIONS
- I understand that massage treatments are considered “non-essential/elective”. They are neither urgent, nor medically necessary, and could be delayed for a minimum of three months without undue risk to my current or future health.
- I understand that COVID-19 has been labeled a world-wide pandemic and is considered to be highly contagious.
- I understand that, while the staff at Body Heal Thyself Massage Therapy is following state guidelines and has implemented reasonable preventative safety measures including, but not limited to: increased sanitation of surfaces, wearing of masks, gloves, and other measures all aimed to reduce the spread of COVID-19, there is no way to eliminate the risk from COVID-19.
- I understand that COVID-19 is believed to spread by person-to-person contact or through the touching of fomites. As a result, there is a possibility that this virus could be contracted while visiting the facility, as a 6 - foot social distancing cannot be maintained during treatments.
- I understand that testing negative for COVID-19 or positive for antibodies from prior exposure to COVID-19 does not necessarily determine if the virus is present or has ever been present.
- I understand that individuals who are 65 years and older; with chronic lung disease or moderate to severe asthma; who have serious heart conditions; who are immunocompromised; pregnant women; or determined to be high risk by a licensed healthcare provider are considered Vulnerable Individuals by the Colorado Department of Public Health and Environment and are at increased risk from COVID-19. If I am considered a Vulnerable Individual, I consent to my elective treatment with full understanding of my increased risk.
- I AM AWARE AND UNDERSTAND THAT BY PARTICIPATING IN NON-ESSENTIAL/ELECTIVE TREATMENTS MAY INCREASE MY RISK OF CONTRACTING COVID-19. CONTRACTING COVID-19 IS DANGEROUS AND INVOLVES THE RISK OF SERIOUS INJURY AND/OR DEATH. I ACKNOWLEDGE THAT SUCH INCREASED RISK MAY BE COMPOUNDED BY NEGLIGENCE OF THE COMPANY. I ACKNOWLEDGE THAT I AM VOLUNTARILY ELECTING TO HAVE NON- ESSENTIAL/ELECTIVE TREATMENTSS PERFORMED WITH KNOWLEDGE OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY OR DEATH, WHETHER CAUSED BY THE NEGLIGENCE OF THE COMPANY OR OTHERWISE.
UNDERSTANDING, ACKNOWLEDGEMENT AND CONSENT
❒ I understand all of the above statements. I have been given the opportunity to ask questions. I acknowledge the risk of contracting COVID-19 during my treatment. I am still opting to proceed with my desired treatment today and have declined the option given to me to defer treatment without risk of penalty for cancellation.
______________________________________ _______________ Signature of Patient (or Parent or Guardian) Date
Consent Renewal – I hereby reconsent to this COVID-19 Known Risk Consent Form & Waiver of Liability. I have not had symptoms, travel, contact or other contraindications as described above since my last visit.
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