Precautionary Coronavirus Liability Release Form

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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.

Symptoms of COVID-19 include:
- Fever
- Fatigue
- Dry cough
- Difficulty breathing

Name *

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 14 days. *

Type in your initials.

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

Type in your initials.

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

Type in your initials.

I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days. *

Type in your initials.

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

Type in your initials.

I understand that because spa treatments involve maintaining touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. *

I agree

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