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Covid-19 Client Intake Questionnaire/ Consent for Therapy and Waiver of Liability
1. Current Temperature ___________°F
2. My temperature has not been above 98.6°F in the past 72 hrs. ____
3. I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks. ____
4. I have not had any of the following symptoms in the past 2 weeks: Fever, Cough, Shortness of Breath,
Persistent Chest Pain or Pressure. ____
5. I acknowledge I am receiving Massage Therapy knowing that social distancing cannot be adhered to
during my massage session. ____
6. In the event I contract Covid-19, I will notify my therapist as soon as possible. ____
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. Your Massage
Therapist has put in place preventative 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 COVID19 and voluntarily assume the risk that I may be exposed to or
infected by COVID-19 by receiving massage therapy 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 appointment. On my behalf I hereby release, covenant not to sue,
discharge, and hold harmless my massage therapist, their massage establishment, 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 the establishment where massage therapy services are received,
whether a COVID-19 infection occurs before, during, or after participation in any massage therapy session.
I understand that a Massage Therapist does not diagnose disease, illness, or prescribe any treatment or drugs,
nor do they provide spinal manipulation. I understand that draping will be used at all times and that breast
massage will not be administered on female clients. I consent to gluteal massage when medically
necessary. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will
inform the health care provider of any changes in my status. I hereby assume full responsibility for receipt of
massage therapy, and releases and discharge the Therapist from any and all claims, liabilities, damages, actions,
or causes of action arising from the therapy received hereunder, including, without limitation, any damages
arising from acts of active or passive negligence on the part of the Therapist , to the fullest extent allowed by
law. Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees
that this Consent will apply to and govern the current and all future therapy sessions performed by Therapist.
We may disclose your health information to a HIPAA certified Business Associate. I understand that for my
protection, any requests to amend my health information or to access my medical records must be made in
writing. I have read the HIPPA privacy act and agree to its conditions.
Client’s name printed____________________________________________ Date______________________
Client’s signature____________________________________________
The undersigned hereby freely consents to receipt of services from: Amanda Lux LMT, BCPP