Symptoms of COVID-19 include:
• Fever • Fatigue • Dry Cough • Difficulty Breathing
I AGREE TO THE FOLLOWING:
∎ I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
∎ I affirm that I, as well as all household members, have not been diagnosed with, or tested positive with COVID-19 within the last 30 days.
∎ I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with, or has tested positive for COVID-19 within the last 30 days.
∎ I affirm that I, as well as all household members, have not traveled outside of the US or to any city outside Columbus which would be considered a “hot spot” for COVID-19 infections within the last 30 days.
∎ I understand that this business and my massage therapist cannot be held liable for any damages caused by or related to exposure to the Coronavirus, or any other contagion or communicable disease due to inaccurate information on this form or any health history provided by any client.
By agreeing to each of the above statements, I release my massage therapist and TMC Medical Massage & Movement
from any and all liability for the unintentional exposure or harm due to COVID-19.
Your massage therapist and all employees of this facility agree that they abide by the same standards and affirm the
same. We also affirm we have improved and expanded our sanitation protocols to more thoroughly fight the spread
of COVID-19 and other communicable conditions.
Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold
or the flu, you may be exposed to COVID-19, also known as “Coronavirus”, at any time or in any place. Be assured
that we have always followed state and federal regulation and recommended disinfection protocols to limit
transmission of all diseases in our office and continue to do so.
Despite our careful attention to disinfection, there is still a change that you could be exposed to an illness in our
office, just as you might be at your gym, grocery store or favorite restaurant. “Social Distancing” nationwide has
reduced the transmission of the Coronavirus. Although we have taken measurements to provide social distancing in
our practice, due to the nature of the services we provide, it is not possible to maintain social distancing between
client, therapist, office staff and sometimes other clients, at all times.
