COVID-19 Symptom & Liability Waiver – Joyce Calvitti, LMT

Client Name: (please print) _____________________________________Date:______

In the last 24 hours have you had a fever of 100°F or above?  Yes ☐No☐

Within the last 10 days have you experienced any of the following:

Respiratory or Flu Symptoms such as  Fever, Shortness of Breath or Difficulty Breathing, Cough, Chills, Digestive Issues, Headache or Extreme Fatigue?   Yes ☐No ☐   Circle any that apply

New Loss of Taste or Smell?  Yes ☐No ☐

Sore Throat?  Yes ☐No ☐

Unusual Aches or Pain?  Yes ☐No ☐

I agree to notify Joyce Calvitti, LMT if I experience any of the above symptoms during the next 10 days for Contact Tracing purposes. For preventative reasons only. No liability will be held.                    

Signature ___________________________________

In the last 10 days have you been in Close Contact (w/o PersonalProtectiveEquipment) with anyone diagnosed with COVID 19/COVIDVariants or who has Coronavirus-Type Symptoms?  Yes ☐No ☐

Within the last 2 weeks have you been diagnosed with COVID 19/COVID Variants?   Yes ☐No ☐   

If YES, have you since had 2 consecutive Negative tests?  Yes ☐No ☐

Consent for Treatment:

I understand that because Massage Therapy work involves maintained touch and close physical proximity over an extended period of time there may be an elevated risk of disease transmission, including COVID-19/COVID Variants, during my session.

I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless Joyce Calvitti LMT, from any claims related thereto. I give my consent to receive treatment from this practitioner.

By signing this form, I agree to wash/sanitize my hands before and after treatment. I agree to wear a mask during entire treatment to minimize that risk.

Client Signature: __________________________________________Date:_______

Parent or Guardian Signature: ________________________________Date:_______