Covid-19 Risk Informed Consent

Name

First Name

Last Name

I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

Initial

I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because massage therapy involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to Bethiah Rosa, CMT of House of the Home to proceed with providing massage therapy.

Initial

I agree that I will notify House of the Home if I test positive for COVID-19 and have received a massage in the last 14 days.

Initial

By signing this form, I knowingly and willingly consent to receiving massage therapy treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I appreciate that it is not possible to consider every possible complication to care. I intend this consent to cover the entire course of care from House of the Home

Signature (Example: /Bethiah Rosa/)

Date

YYYY

Studio sessions:

Both client and therapist are required to wear masks for the entirety of the session.
Hand sanitizing upon arrival for session is required.
Each treatment room is thoroughly sanitized between clients and is equipped with a HEPA filter air purifier.
Time between sessions has been extended to refresh the treatment rooms.
The office is regularly deep cleaned.

In-home sessions:

Both client and therapist are required to wear masks for the entirety of the session.
Hand sanitizing upon arrival for session is required.

HOUSE OF THE HOME

COVID-19 SAFETY

Covid-19 Risk Informed Consent

Studio Sessions

In-Home Sessions

bethiah@houseofthehome.com