COVID 19 WAIVER

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

You agree to reschedule if you cared for someone diagnosed with COVID-19 within 14 days of this appointment. *

I Agree

You agree to reschedule if you experienced any cold or flu-like symptoms within 14 days of this appointment. *

I Agree

Have you traveled outside of Connecticut in the last 14 days? *

Yes

No

If you have traveled outside of Connecticut, did you self quarantine for the last 14 days? *

Yes

No

I have not traveled in the last 14 days

You agree to wear a mask at all times while in the facilities of Elm City Wellness. *

I Agree

You agree to have your temperature taken upon arrival for this appointment. *

I Agree

You have not knowingly been in contact with anyone diagnosed with COVID-19 in the past 72 hours. *

I agree

Your temperature has not been above 98.6F in the past 72 hours. *

I Agree

You have not had any of the following symptoms in the past two weeks: Fever, shortness of breath, persistent chest pain or pressure. *

I Agree

You acknowledge that you are receiving Massage Therapy or Acupuncture knowing that social distancing cannot be adhered to during your session. *

I Agree

In the event that you contract COVID-19, you will notify Elm City Wellness as soon as possible. *

I Agree

COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. Elm City Wellness has put in place preventive measures to reduce the spread of COVID-19; however, your Massage Therapist cannot guarantee that you will not become infected with COVID-19. 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 my mere presence within this establishment and that such exposure or infection may result in personal injury, illness, permanent disability and death. 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 Massage Therapy or Acupuncture appointment. On my behalf I hereby release, covenant not to sue, discharge, and hold harmless my massage therapist, Elm City Wellness, and any interested parties 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, omissions or negligence of my massage therapist or Elm City Wellness, whether a COVID-19 infection occurs before, during or after participation in any massage therapy session. *

I agree to all the above

First Name

Last Name