COVID-19 Health Information & Liability Wavier



COVID-19 Health Information & Liability Wavier

Please fill out and send back before your appointment day.

Email to: Mobile1MassageTherapist @

Or photograph and text to: 949-923-9999

As per Mobile 1 Massage website:

WE ARE TAKING COVID-19 PRECAUTIONS, WHILE WORKING WITH YOU.

We will be asking questions about your health & "shelter in place" experience.  

ALL clients will need to sign a newly revised Consent & Release form before their appointment.

It is pertinent that ALL clients SHOWER & WEAR FRESHLY LAUNDERED & non scented clothing before EVERY appointment. 

For the benefit of all, massage therapists will be working with masks on.

1. Where have you traveled outside of Orange County in the last 2-4 weeks?

___________________________________________________________________

2. Have you had a fever in the last 24 hours of 100°F or above? Yes ☐ No ☐

3. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? Yes ☐ No ☐

3. Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? Yes ☐ No ☐

4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has corona virus-type symptoms? Yes ☐ No ☐

Do you have special needs I should prepare for: __________________________________________________________________________________________

Do you have any questions or concerns:

__________________________________________________________________________________________

If out-call, are there any specific directions, parking, or instructions:

__________________________________________________________________________________________

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 elevated risk of disease transmission, including COVID-19. By signing this form, 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 the practioner/business form any claims related there to. I give my consent to receive treatment form this practioner.

Client Signature:______________________________________________ Date: _________________________

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