C-19 Screening / Informed Consent

Massage Professionals of Jackson Hole

Coronavirus Screening/Informed Consent Form

MPJH must assume that our clients are unaware that the risk of infection from COVID-19 increases through close contact with other people, like the level of contact required to provide massage. Therefore, we must inform you as a client of this risk and obtain your signature indicating that you understand the risk and wish to receive massage therapy.

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.

Symptoms of COVID-19 include:

• Fever                                                                 • Fatigue                                            

• Dry cough                                                        • Difficulty breathing / shortness of breath

• Chills/Aches/Pains                                       • Nausea or vomiting

• Diarrhea                                                           • Confusion

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 COVID19 within the last 30 days.  I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.  I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.  I also have not visited an elderly care facility in the last 14 days.  I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

By signing below, I agree to each statement and release the massage therapist and business from any and all liability for the unintentional exposure or harm due to COVID-19.

“I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this therapist working for MPJH.”

Your massage therapist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Because of the length of time in close proximity the therapist is in with the client the risk of contracting the C19 virus is dramatically increased.  Therefore, Massage Professionals of Jackson Hole require that both the client and the therapist wear a face mask/covering.  Refusal to comply with wearing a face covering is reason to deny service.

“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.”

 “Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, Massage Professionals of Jackson Hole and their employees, contractors, owners and representatives, successors, assignees, governing bodies, and advisory committees from any and all claims, demands, actions and causes of action, which may result from services rendered.”

Signature _________________________________________________________   

Date _____________________