Health and Safety Liability Form

Client Health and Safety Liability Form

To ensure the protection of all, the following Health and Safety Liability Form will be issued in person before each session and will require signature before proceeding with services from AIM Massage Therapy.

The World Health Organization and US Centers for Disease Control has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to the nature of Massage Therapy and the capacity for COVID-19 to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines and some prohibitions which AIM Massage Therapy adheres to comply.

In consideration of my participation in Therapeutic Massage services from AIM Massage Therapy, I acknowledge and agree to the following:

• I understand that because Massage Therapy involves close physical proximity over an extended period of time, there may be an elevated risk of infection and disease transmission, including COVID-19.

• I voluntarily seek services provided by AIM Massage Therapy and acknowledge that I must comply with all set procedures to reduce the spread of infections and diseases while attending my appointment.

• I acknowledge that I follow health and safety procedures in my home/facility set by health administrators and continue to limit my exposure to infections and diseases, including cleaning and disinfecting frequently touched objects and areas designated for Therapeutic Massage service.

• I understand that the risk of becoming exposed to, infected and/or harmed by any infection or condition may result from the actions, omissions or negligence of myself and others. Therefore, to the best of my ability, I will maintain honesty of my health status and inform my Massage Therapist of all conditions I am aware of.

Following the pronouncements above, I hereby declare the following:

• I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, nasal congestion, sore throat or new loss of taste or smell.

• I affirm that I, as well as all household members, have not been diagnosed with COVID-19, or any communicable disease, within the last 14 days.

• I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19, or any communicable disease, within the last 14 days.

• I affirm that I, as well as all household members, have not traveled outside of the country, or to any place that is or has been considered a “hot spot” for COVID-19 or other communicable diseases, within the last 14 days.

If you can not honestly answer YES to any of the above statements, you will be asked to reschedule your appointment for another day. No cancellation fee will be applied.