COVID Intake Form

Name *

First

Last

Address *

City / State / Zip: *

Phone Number *

Email *

My temperature has not been above 98.6°F in the past 72 hrs.? *

Yes
No

I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks. *

Yes
No

I have not had any of the following symptoms in the past 2 weeks: Fever, Cough, Shortness of Breath, Persistent Chest Pain or Pressure. *

Yes
No

I acknowledge I am receiving services knowing that social distancing cannot be adhered to during my session. *

Yes
No

In the event I contract Covid-19, I will notify my service provider as soon as possible. *

Yes
No

Please take a moment to carefully read the following information and sign (fill in your full name) where indicated. *

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. WombmenThings have put in place preventative measures to reduce the spread of COVID-19; however, we 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 receiving our services and 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 service appointment. On my behalf I hereby release, covenant not to sue, discharge, and hold harmless Noni Brown, or WombmenThings, 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 service provider or the establishment where services are received, whether a COVID-19 infection occurs before, during, or after participation in any massage therapy session.