CORONAVIRUS RELEASE FORM

Precautionary Coronavirus Liability Release Form

How are you feeling today?

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 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 COVID-19 within the last 30 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 provide by each client.

First Name

Last Name

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thank you!

Precautionary Coronavirus Liability Release Form

HOURS

CONTACT INFO