INFORMED CONSENT FOR SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS

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Cassidy's Massage Therapy

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My Commitment to Minimize Exposure

I will be taking every precaution to make my studio a sanitary and safe environment. For starters, I will be wearing a mask at all times during our sessions. As always, I will practice proper hand washing protocol and have a minimum 30 minute buffer between clients to be sure that every surface and item the client comes into contact with is properly sanitized. This includes: table, face cradle, bench/chairs client sits on, hooks client places clothes on, the stool I sit on (and lever to adjust), bolster used, tissue box, desk, credit card machine (my phone), lotion/oil bottles you have touched/used, light switches, door handles, etc. I will also have HEPA air purifiers running in both rooms.

My biggest concern is practicing the most strict safety measures. When I do reopen, I want to stay open! I want to open knowing that I am doing everything that I can to ensure public health and safety, not only for you but for each of us.

Your Responsibility to Minimize Your Exposure - To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, other clients, and our families) safer from exposure, sickness and possible death. Your failure or refusal to adhere to these safeguards may result in postponing our client/massage therapist relationship until this unprecedented health crisis is over. Put a checkmark on each to indicate that you understand and agree to these actions: *

You will wear a mask in all areas of the office at all times (I will have masks available for $1)

You will wash your hands or use hand sanitizer upon arrival.

You will only keep your in-person appointment if you are symptom free.

You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment. If you wish to cancel for this reason, I won't charge you my normal cancellation fee.

You will wait in your car or outside until no earlier than 5 minutes before our appointment time.

You will try not to touch your face or eyes with your hands. If you do, you will immediately sanitize your hands.

If you have a job that exposes you to those who are infected, you will let me know.

If a resident of your home tests positive for the infection, you will immediately let me know.

If you have had COVID-19 you must be 2 weeks symptom free before coming to your session.

Required

Risks of Opting for In-Person Services - You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). Do you understand the potential risk of receiving bodywork, despite the precautions? *

Yes

COVID-19 Client Screening Questions

You must be able to answer "No" to the next 4 questions in order to visit Cassidy's Massage Therapy.

Have you been out of the country in the last 14-Days? *

Yes

Have you been in contact with anyone with confirmed COVID-19 in the last 14-Days? *

Yes

Have you had a fever greater than 100 degrees in the last 14-Days? *

Yes

Have you had difficulty breathing or a cough in the last 14-Days? *

Yes

If You or I Are Sick

You understand that I am committed to keeping you, me, my other clients, and all of our families safe from the spread of this virus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately.

If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details of the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.

Type your name in the box below to signify that you agree to these terms and conditions. *

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