COVID-19 Screening, Informed Consent, and Liability Form

COVID-19 form

Due to the ongoing pandemic of COVID-19, we are taking extra precautions including temperature checks, mandatory masking, HEPA filtration, and disinfecting practices. However, we cannot guarantee that you will not become infected with COVID-19, and visiting our establishment could increase that risk. Because COVID-19 is still an emerging pathogen, its long-term effects and risks are not fully known. If you or someone you have close contact with is at high risk for complications due to COVID-19, you may wish to delay scheduling until you are fully vaccinated/boosted. Please consider these risks before scheduling your appointment or registering for class.

We ask that you prepare for your visit with the same care and consideration as you would before visiting a cherished grandparent: the next client your therapist or teacher sees 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 deny service. Please don’t put us in that position. We are operating with limited availability and our therapists cannot replace your appointment with another if we don’t have sufficient notice. We also ask that if you follow CDC guidelines regarding quarantine and isolation and that you delay scheduling your appointment if you have had recent contact with anyone who is likely covid positive.

Some of our procedures and policies have changed, and certain services and equipment may not be available. This form and all necessary intake paperwork must be filled out in advance. Please arrive 5-10 minutes early to accommodate screening procedures. If you arrive late, or have not filled out your paperwork in advance, your session length will be reduced accordingly. During your visit, we ask that you keep conversation to a minimum to avoid unnecessary respiratory droplets in the air. Please bring your own water if needed, but otherwise leave unnecessary belongings in your car. If you need special accommodations in terms of positioning or equipment (eg bolstering) please contact us in advance so that we can prepare.

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

In the last 14 days, have you attended social gatherings, restaurants, or other events outside the home where you were unmasked?

Yes

Please elaborate on the type(s) of contact you have had in the last 2 weeks.

If you have been tested for COVID-19, flu, or other respiratory illness in the last 9 months, please list type and results.

Have you received a COVID-19 vaccine?

Yes, I am fully vaccinated and boostered.

Yes, both doses (or 1 dose of J&J)

I've received the first dose but not the second.

I do not wish to share this information.

OtherOther

If applicable, please upload an image of your completed vaccination card. Sharing your vaccination record is optional and is only required if you would like to take advantage of modified policies for those with vaccinated status.

Maximum upload size: 52.43MB

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 appointment, I agree to contact Myo so that my appointment can be rescheduled. *

I agree

I understand that if I arrive for my appointment with any possible symptom of COVID-19, I will be refused service. 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 of my visit. *

I agree

In the event that I develop symptoms or test positive for COVID-19 within 14 days after my appointment, 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

Cancellations are permitted without penalty up to 12 hours before the scheduled start time. In the event that I develop symptoms of COVID-19 within this 12 hour period, cancellation fees may be waived, but only if I provide notice as soon as reasonably possible. No-shows and cancellations within the 12 hour period will be charged 50% of the non discounted service price. I agree to pay all cancellation fees in accordance with Myo policy. *

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 receiving treatment at this time, and I give my consent to receive treatment 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 Screening, Informed Consent, and Liability Form

The Myo Institute

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