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Sign In
My Account
Cart
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BOOK ONLINE
774 Orange St. location
Email Appointment Request
GIFT CARDS
Deals & Specials
Classes & Workshops
Couples Massage Workshop
SERVICES
SKIN CARE & FACIALS
MASSAGE & BODYWORK
ACUPUNCTURE & EASTERN THERAPIES
Craniosacral Therapy
Waxing, Brow & Lash Services
Package Rates & Discounts
CBD Products & Services
CBD Herbal Massage
What Is CBD?
What Is the Endocannabinoid System and What Is Its Role?
Should I try CBD? FAQs
CBD and Sleep
CBD Research Studies
CBD Products at Elm City Wellness
CBD Massage Intake Form
Come as you are. Leave feeling better.
Your Neighborhood Wellness Blog
Plan Your Visit
Mailing List
Location / Contact Us
Policies
Intake forms
New to Massage?
Are you a(n)...?
Groupon, Living Social, etc.
About Us
Staff Bios
Benefits of massage therapy
Massage & Pain Management
Benefits of acupuncture
We're Hiring!
Corporate & Event Massage
COVID 19 WAIVER
Name
*
First Name
Last Name
Email Address
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors,
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important and required to help us take precautionary measures to protect you and everyone in this building.
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 yes, where did you go?
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
Thank you!