COVID-19 Liability Release Waiver
**Signature Required Prior to Every Scheduled Appointment**
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), HealingGround is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfection procedures in accordance with the Wisconsin Department of Safety and Professional Services guidance.
Symptoms of COVID-19 include:
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 COVID-19 WITHIN THE PAST 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 PAST 30 DAYS.
[ ] I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS.
[ ] I understand that HealingGround cannot beheld liable for any exposure to the COVID-19 virus caused by on this form or the health history provided by each client.
HealingGround is following these enhanced procedures to prevent the spread of COVID-19:
Prepayment for services available or electronic invoicing if clients prefer contactless checkout
Additional time included between appointments to prevent client contact with each other
Guests accompanying those scheduled for services discouraged
Each client required to wash hands upon arrival and before leaving
Your therapist will thoroughly clean hands and wear nitrile gloves during all treatments
Your therapist will wear a clean set of arm coverings, cloth mask, and an apron for each client
All product bottles used during treatment will be placed on the trolley for disinfection and disposable items will be used when possible
All surfaces will be wiped thoroughly with hospital grade disinfectant before and after each client according to the manufacturer's directions.
By signing below, I agree to each statement above and release HealingGround from any and all liability for the unintentional exposure or harm due to COVID-19.
The therapist agrees to abide by these standards and affirms the same.