COVID19 INFORMED CONSENT FORM

 **This form will be part of the online intake form, with an electronic signature, and is posted here for easy reference and decision making. A downloadable version is below.

Roots to Bloom - Prenatal Massage Tucson
COVID 19 Informed Consent Form 
Last Edit: 5/16/2020 
Important Information about CV19, known risk factors, and massage therapy 

COVID 19 is present in Pima County as well as around the world. The fact that individuals can feel healthy and free of symptoms during the incubation period while passing it on to others makes this virus a serious public health risk. 
Our Goals: 
1. Reduce morbidity and mortality 
2. Minimize disease transmission 
3. Protect healthcare personnel 
4. Provide therapeutic touch and stress relief to current and potential clients 
5. Ensure the continuation of services provided in this office 
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html 
In order to help reduce the spread of coronavirus, and to the best of Roots to Bloom therapist and clients ability to reduce the transmission risks to each other, these additional precautions and guidelines will be enforced:
Mask wearing will be mandatory for BOTH client and therapist from entering the property until after treatment has ended.

• Avoid at all times touching the face; eyes, nose, mouth.
• The therapist will continue to follow strict disinfection protocol between clients. (see document)
• Your appointment can be rescheduled for a later time if any high-risk categories apply to you or members of your household. 
• Please complete this questionnaire to acknowledge your understanding of the virus and to screen for risk factors. 

This screening list was taken from the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#high-risk 
COVID-19 Risk Factor Screening Questionnaire
Please Check any categories that apply to you. 

❏ My age is over 65 years old 
❏ I have lung disease or moderate to severe asthma 
❏ I have heart disease that is not regulated, or with complications 
❏ I am immunocompromised or going through cancer treatment 
❏ I have a history of blood clots or am high risk for blood clots 
❏ I have other conditions, such as diabetes, renal failure, or liver disease 
❏ I am pregnant or trying to become pregnant 
❏ I have travelled out of the country within the last 15 days 
❏ I have been exposed to someone who has tested positive for COVID 19 within 
the last 15 days 
❏ I live in a nursing home or long term care facility 
❏ None of these categories applies to me 

Please read and sign the statement below:
I understand that COVID 19 is a highly contagious respiratory infection that is potentially life-threatening in individuals with the risk factors listed above. I am aware that my massage therapist may decide to reschedule if I or they have been sick, febrile, or have any of the above-listed risk factors according to his or her discretion. I have had the opportunity to ask questions and seek clarification with my massage therapist. I also have a clear understanding that both myself and my therapist are accepting the potential risks of touch-based therapies, and I will not hold my therapist liable if I acquire COVID 19. 

________________________________ ________________________________ Signature Printed Name 
Today’s Date: _______________
___________________________ _____________________________________Massage Therapist Signature 

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