BY APPOINTMENT ONLY
THIS IS OUR COVID-19 STANDARDS AND PROCEDURES FORM THAT WE WILL HAVE YOU ACKNOWLEDGE, FOLLOW AND SIGN. IF YOU WOULD LIKE TO FILL IT OUT AHEAD OF TIME HERE IS THE LINK.
THANK YOU FOR YOUR COOPERATION AND UNDERSTANDING.
MASSAGE AND BODYWORK CONSENT AND AFFIRMATION FORM
COVID - 19 REOPENING
1). I knowingly and willingly consent to bodywork at Centered Self by Emilee Huff during the reopening phase of COVID-19 and thereafter.
2). I understand that a mask must be worn by myself and the therapist the moment I enter the establishment until the moment that I leave. If I am having trouble breathing during the massage a special circumstance may be observed. I understand I am to be careful of only touching items that are necessary for me to touch during my stay. I understand my temperature will be taken upon arriving.
3). I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID-19 viral testing.
4). Risk of transmission: I understand that due to the frequency of visits of other clients, characteristics of the virus, and given location, that I have an elevated risk of contracting the virus simply by entering the establishment, even though standard precautions are being observed.
5). I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID-19 in the last 30 days and that I am not presenting with any of the following symptoms of COVID-19:
A. Fever of 100.5 degrees Fahrenheit or 37 degrees PCelsius or higher B. Shortness of Breath
C. Dry cough
D. Runny nose
E. Sore throat
F. Diminished sense of taste or smell
6). Contact with infected: I confirm that I have not knowingly been in close contact (defined as feet or less for a duration of 15 minutes or more) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in paragraph 5 (#5) in the last 14 days.
7) Public Travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.
INFORMED CONSENT: I have been given the opportunity to ask questions regarding the risks of contracting COVID-19 from Centered Self LLC. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all risks and responsibility as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the bodywork recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions.