INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.
Decision to Meet Face-to-Face
We have agreed to meet in person for massage therapy sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we cancel your massage appointment/s. If you have concerns, I’m happy to address any issues. You understand that, if I believe it is necessary, I may determine that we reschedule your massage appointment if you show any COVID-19 symptoms. (Cough, Fever, Shortness of Breath)
If you decide at any time that you would feel safer canceling your massage due to symptoms of Covid-19 or were in close contact with someone who has Covid-19, I will respect and appreciate that decision.
Risks of Opting for In-Person Services
You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
Your Responsibility to Minimize Your Exposure
To obtain services, you agree to take certain precautions which will help keep everyone (you, me, and our families, [my associates] and other clients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in no longer offering you services at our office. Initial each to indicate that you understand and agree to these actions:
- You will only keep your in-person appointment if you are symptom free. ___
- You or I will take your temperature before entering our office to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment. If you wish to cancel for this reason, I won’t charge you our normal cancellation fee. __
- You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time. ___
- You will wash your hands or use alcohol-based hand sanitizer when you enter the office. ___
- You will adhere to the safe distancing precautions we have set up in the waiting room and therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.___
- You will wear a mask in all areas of the office (I [and my associates] will too). ___
- You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or my associates]. ___
- You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. ___
- Please do not bring others into the office, if necessary make they must follow all of these sanitation and distancing protocols. ___
- You will take steps between appointments to minimize your exposure to COVID. ___
- If you have a job that exposes you to other people who are infected, you will immediately let me [and my associates] know. ___
- If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me [and my associates] know. ___
- If a resident of your home tests positive for the infection, you will immediately let me [and my associates].___
I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will email you about any necessary changes.
My Commitment to Minimize Exposure
My practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts.
If You or I Are Sick
You understand that I am committed to keeping you, me, [my associates] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my office associates] believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with by phone or as appropriate.
If I [or my associates] test positive for the coronavirus, I will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection
If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.
This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.
Your signature below shows that you agree to these terms and conditions.