I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Lisa Inoue LMSW PLLC put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Lisa Inoue LMSW PLLC can not guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others.
I voluntarily seek services provided by Lisa Inoue LMSW PLLC and acknowledge that I may be increasing my risk to exposure to the Coronavirus/COVID-19 through accessing therapy services in an office setting. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Lisa Inoue LMSW PLLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Lisa Inoue LMSW PLLC, or that may otherwise arise in any way in connection with any services received from Lisa Inoue LMSW PLLC. I understand that this release discharges Lisa Inoue LMSW PLLC from any liability or claim that I, my heirs, or any personal representatives may have against her therapy practice with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Lisa Inoue LMSW PLLC. This liability waiver and release extends to all tenants located within 5340 Plymouth Rd. as well as the owners of 5340 Plymouth Rd.
I am also aware that Lisa Inoue LMSW PLLC may need to disclose my presence in therapy in the event of my or my therapist contracting Coronavirus/COVID-19 due to compliance with applicable public health laws.