Basic Kneads Massage COVID-19 Release Form

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This form is provided for long term, ongoing clients. Please note that this form will be accepted as a blanket health screening for ongoing treatment, but should your treatment schedule lapse for 30 days, a new form will need to be completed. Please also note that I reserve the right to ask you to complete additional forms as treatment progresses as I feel is necessary.

**PLEASE READ EVERYTHING CAREFULLY**

Email *

First and Last Name *

Please read carefully and check each box below. *

I will notify my therapist immediately if I have been in contact with a confirmed case of Covid-19 in the 14 days prior to each appointment.

I will notify my therapist immediately if I have any of the following symptoms in the 14 days prior to all appointments: fever (temp over 100.4), cough, shortness of breath, sore throat, runny nose, new loss of taste and/or smell, or gastrointestinal issues (diarrhea, nausea, vomiting).

I will notify my therapist immediately if I have had a fever of 100 degrees or higher in the 24 hours prior to all appointments.

Required

By typing my initials below I acknowledge that I understand my name and contact information might be shared with the state health department in the event that a client or practitioner at the studio tests positive for Covid-19. *

By typing my initials below I acknowledge and understand that if I develop any symptoms of Covid-19, or test positive for the virus within 14 days of my appointment at Basic Kneads Massage, that I am being asked to immediately report it by calling Jennifer at 906-420-0990. *

To proceed with receiving care, I confirm and understand the following. Check all boxes provided. *

I understand that Covid-19, which has been declared a global pandemic by the World Health Organization, is extremely contagious, can be contacted from various sources, and due to it's long incubation period and asymptomatic carriers it can be exceptionally difficult to identify those who are infected with the coronavirus.

I understand preventable measures and intensified sanitation protocols have been implemented and are strictly met to reduce the spread of Covid-19

I hereby acknowledge and assume the risk of becoming infected with Covid-19 through this treatment and give my permission to you to proceed with providing care.

Required

Today's date *

YYYY

A copy of your responses will be emailed to the address you provided.

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