COVID-19 Questionnaire & Liability Waiver

Essentials Massage Therapy LLC, COVID-19 Questionnaire & Liability Waiver

We want to assure you that we are doing everything under our control to follow all CDC/WHO/Forward Virginia guidelines. We have put in place some updated safety measures to minimize the risk of contracting the novel Covid-19. We will be checking our staff’s temperature each day before work & they will be sent home if they have a temperature over 100. Our staff must wear face coverings when interacting with clients & performing massages. They must also wash their hands with soap and water for at least 20 seconds before and after each massage. As always, we will be using clean linens for each massage. We are leaving extra time between each client for the massage tables, headrests and treatment rooms to be thoroughly cleaned & disinfected before each massage. We will also be performing thorough cleaning & disinfection of frequently touched surfaces every 60 minutes.

Thank you for being here with us. We are all in this together and we appreciate your business. Below is a questionnaire and liability waiver that we would appreciate you filling out & signing prior to your therapeutic massage.

COVID-19 Client Questionnaire:

  • Have you had a fever in the last 24 hours of 100°F or above?
  • Do you now, or have you recently had any respiratory or flu symptoms, cough, chills, sore throat, new loss of taste or smell, or shortness of breath?
  • Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Consent for Treatment

I understand that, because massage therapy work involves maintained 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, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner and/or Essentials Massage Therapy LLC from any claims related thereto. I give my consent to receive treatment from this practitioner.

Client Signature (or Parent or Guardian Signature in case of a minor):