Risk Informed Consent for COVID-19 We are taking extra precautions due to COVID-19 pandemic with the intake of each client. Please answer these questions truthfully so we may continue to do our best to stop the spread of this deadly disease. Symptoms may include: New or worsening cough Yes No Shortness of breath Yes No Sore throat Yes No Runny nose, sneezing or nasal congestion Yes No Hoarse Voice Yes No Difficulty swallowing Yes No New taste or smell disorder(s) Yes No Nausea/vomiting, diarrhea, abdominal pain Yes No Headache Yes No Fever Yes No I,* • I accept the following affirmations when engaging in a massage from a Good Sign Registered Therapist. • I understand the above symptoms and affirm that I, as well as all members of my household, do not currently have nor have experienced COVID-19 within the last 14 days. • I claim that I, as well as members of my households, have not diagnosed with COVID-19 within the last 14 days. • I claim that, to my knowledge, I have not been in contact with anyone who has been diagnosed with COVID-19. • I claim that if I traveled outside of Canada in the last month, I isolate myself in my home for 14 days upon my return. • I understand that this business and my Good Sign Massage Registered Therapist can not be held liable should I experience exposure to the virus or any other contagion as a result of my providing misinformation on this form. • I understand that because massage therapy and other natural health practices involve maintaining prolonged and close physical contact, there may be an elevated risk of disease transmission, including COVID-19. • I acknowledge that I am aware of the risks involved and give consent to receive massage therapy by signing this form.• I accept the following affirmations when engaging in a massage from a Good Sign Registered Therapist. • I understand the above symptoms and affirm that I, as well as all members of my household, do not currently have nor have experienced COVID-19 within the last 14 days. • I claim that I, as well as members of my households, have not diagnosed with COVID-19 within the last 14 days. • I claim that, to my knowledge, I have not been in contact with anyone who has been diagnosed with COVID-19. • I claim that if I traveled outside of Canada in the last month, I isolate myself in my home for 14 days upon my return. • I understand that this business and my Good Sign Massage Registered Therapist can not be held liable should I experience exposure to the virus or any other contagion as a result of my providing misinformation on this form. • I understand that because massage therapy and other natural health practices involve maintaining prolonged and close physical contact, there may be an elevated risk of disease transmission, including COVID-19. • I acknowledge that I am aware of the risks involved and give consent to receive massage therapy by signing this form. I agree to the privacy policy.Client's Signature*Treatment Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
