COVID-19 Staff Member Agreement

COVID-19 Therapist agreement

Due to the ongoing pandemic of the novel Coronavirus, COVID-19, we are taking extra precautions including health screening, temperature checks, mandatory masks for all clients and staff, HEPA filters, and sanitation and disinfecting practices between every client. However, we cannot guarantee that you will not become infected with COVID-19, and working with clients at Myo could increase that risk. Because COVID-19 is still an emerging pathogen, its long-term effects and risks are not fully known. Please consider these risks before committing to come back to work.

We ask that you prepare for your shifts with the same care and consideration as you would before visiting a cherished grandparent: your client may well be one! If you have any sign of illness please contact us with as much notice as possible. We will be checking temperature on arrival, and if you have a temperature, cough, or any other symptom we WILL send you home. Please don’t put us, or your clients, in that position. As much as possible, we also ask that you practice proper distancing and refrain from engaging in any behavior that puts you at high risk for contact outside of work.

In the unfortunate circumstance that we have a known Covid-19 exposure event at Myo, any employee or contractor who was in close contact with the infected individual(s) (within 6 feet for more than 10 minutes) must be quarantined for 14 days from the date of last exposure, or with a negative test 7 days after exposure. In the event that you test positive for COVID-19 or show symptoms that could be COVID-19 and do not get evaluated by a medical professional or tested for COVID-19, you may not return to work until all three of the following criteria are met: at least 3 days (72 hours) have passed since recovery (resolution of fever without the use of fever-reducing medications); improvement in symptoms (e.g., cough, shortness of breath); and at least 10 days have passed since symptoms first appeared. If you have symptoms that could be COVID-19 and want to return to work before completing the above self-isolation period, you must obtain a medical professional’s note clearing you for return based on an alternative diagnosis. These protocols may be updated from time to time based on CDC recommendations.

Many of our procedures and policies have changed, and there may be further changes as the situation evolves. Please pay close attention to communications from us and bear with us as we adapt to this new reality. We will provide documentation of new procedures now and as they become available.

Thank you for your help and consideration! We look forward to seeing you.

First Name *

Last Name *

Phone Number *

Do you frequently experience headaches similar to this one?

Yes

Is your muscle pain chronic or recent in origin?

Chronic

Recent

Are you aware of an injury, overuse, or other precipitating event that caused your discomfort?

Yes

Please describe the location and quality of your discomfort.

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes

For the last 14 days, have you been able to maintain social distancing?

Yes

If you have been tested for COVID-19, flu, or other respiratory illness in the last 6 months, please list type and results.

If I develop any possible symptom of COVID-19 as listed above, or have close contact with anyone showing these symptoms within 14 days of my shift, I agree to contact Myo so that my appointments can be rescheduled. *

I agree

I understand that if I arrive for my shift with any possible symptom of COVID-19, I will be sent home. I agree to comply with all screening and safety precautions required by Myo, including wearing a properly fitted mask over my mouth and nose for the entire duration that I am on Myo premises. *

I agree

I certify that I have reviewed and understood the CDC instructions on proper handwashing and use of hand sanitizer and that I will comply with these guidelines each time I wash or sanitize my hands. *

I agree

In the event that I develop symptoms or test positive for COVID-19 within 14 days after any shift, I agree to contact Myo to assist in contact tracing and quarantine efforts. *

I agree

I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department. *

I agree

I understand and will adhere to the policies and procedures that have been presented to me. These policies and procedures may be revised in future, and I agree to adhere to such revisions upon notice. *

I agree

I understand that, because massage therapy and acupuncture involve touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from practicing at this time, and I give my consent to practice at Myo. *

I agree

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 visiting Myo and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Myo may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, contractors, and clients. 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 visit to Myo (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless Myo, its employees, agents, and representatives, of and 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 or omissions of Myo, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after a visit to Myo. *

I agree

My digital signature below certifies my understanding of and agreement with the above policies. *

Clear

COVID-19 Staff Member Agreement

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