In light of the current health crisis, please read all of the information below and fill out this form completely prior to scheduling your massage session.
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic be the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that I am the decision maker for my health care. To the best of his ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of therapeutic massage during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is extremely difficult.
I understand that preventative measures and sanitation protocols intended to reduce the spread of COVID-19 have been implemented . However, because massage therapy involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to Jay Arovas, CMT to proceed with providing care.
I understand that the health conditions listed below place me at higher risk for serious COVID-19 infection. If I have one of these conditions, it is not recommended for me to receive massage therapy while COVID-19 is present in our community without my doctor's consent. Should I decide to proceed with massage therapy, I assume all risk related to COVID-19 infection.
High Risk Health Conditions:
I understand that in the event that a client or the massage therapist tests positive for COVID-19 within a time period that places me at risk of exposure, I will be contacted by the therapist and my name and contact information may be shared with the local Department of Health for their follow-up. In the event that I develop symptoms of illness within 14 days of my massage session, I will contact my massage therapist immediately.
I KNOWINGLY AND WILLINGLY CONSENT TO THE MASSAGE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY ELECTRONICALLY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER MY ENTIRE COURSE OF CARE PROVIDED BY JAY AROVAS, CMT UNTIL SUCH TIME AS I REVOKE IT IN WRITING.