COVID-19 Screening, Informed Consent, and Liability Form

COVID-19 form v2

Due to the ongoing pandemic of COVID-19, we are taking extra precautions including masking, HEPA filtration, and disinfecting practices. However, we cannot guarantee that you will not become infected with COVID-19, and visiting our establishment could increase that risk. Please consider these risks before scheduling your appointment or registering for class.

If you have any sign of illness please contact us with as much notice as possible. If you arrive with possible covid symptoms we WILL deny service. Please don’t put us in that position. We are operating with limited availability and our therapists cannot replace your appointment with another if we don’t have sufficient notice. We also ask that if you are recovering from covid that you delay your visit until your symptoms have resolved and you are testing negative on a rapid test. If you have had recent contact with anyone who is likely covid positive, please delay your appointment until at least one week from your last exposure.

Specific policies such as masking requirements may vary depending on the level of community risk and/or the therapist you are working with. If unmasking during session is important to you, please check if this will be possible before booking your appointment. This form and all necessary intake paperwork must be filled out in advance. Please arrive 5-10 minutes early to settle in before your appointment. If you arrive late, or have not filled out your paperwork in advance, your session length will be reduced accordingly.

Thank you for your help and consideration! We look forward to seeing you.

First Name *

Last Name *

Phone Number *

Do you frequently experience headaches similar to this one?

Yes

Is your muscle pain chronic or recent in origin?

Chronic

Recent

Are you aware of an injury, overuse, or other precipitating event that caused your discomfort?

Yes

Please describe the location and quality of your discomfort.

Have you been in contact with anyone in the last 7 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes

If you have had contact with someone who is likely covid-positive in the last week, we ask that you delay your session.

I understand.

In the last 7 days, have you traveled or attended a large gathering where you were unmasked?

Yes

If you have traveled or attended large gatherings in the last week, we ask that you remain masked during your session even if our current policies allow unmasking otherwise.

I understand.

Have you received a COVID-19 vaccine?

Yes, I am fully vaccinated and boostered.

Yes, both doses (or 1 dose of J&J)

I've received the first dose but not the second.

I do not wish to share this information.

OtherOther

If applicable, please upload an image of your completed vaccination card. Sharing your vaccination record is optional and is only required if you would like to take advantage of modified policies for those with vaccinated status.

Maximum file size: 52.43MB

If I develop any possible symptom of COVID-19 as listed above, or have close contact with anyone showing these symptoms within 7 days of my appointment, I agree to contact Myo so that my appointment can be rescheduled. *

I agree

I understand that if I arrive for my appointment with any possible symptom of COVID-19, I will be refused service. I agree to comply with all screening and safety precautions required by Myo, including wearing a properly fitted mask over my mouth and nose for the entire duration of my visit. *

I agree

In the event that I develop symptoms or test positive for COVID-19 within 7 days after my appointment, I agree to contact Myo to assist in contact tracing and quarantine efforts. *

I agree

Cancellations are permitted without penalty up to 12 hours before the scheduled start time. In the event that I develop symptoms of COVID-19 within this 12 hour period, cancellation fees may be waived, but only if I provide notice as soon as reasonably possible. No-shows and cancellations within the 12 hour period will be charged 50% of the non discounted service price. I agree to pay all cancellation fees in accordance with Myo policy. *

I agree

I understand that, because massage therapy and acupuncture involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, and I give my consent to receive treatment at Myo. *

I agree

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by visiting Myo and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Myo may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, contractors, and clients. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my visit to Myo (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless Myo, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions or omissions of Myo, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after a visit to Myo. *

I agree

My digital signature below certifies my understanding of and agreement with the above policies. *

Clear

If you are human, leave this field blank.

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