- I confirm that I have NOT had close contact with ANY person with acute upper respiratory illness or travelled outside of Canada in the last 14 days?
- I confirm I am NOT currently POSITIVE for COVID-19 or have had close contact with a CONFIRMED case without wearing appropriate PPE.
- I confirm I am NOT presenting with a fever (38 Celsius or 100.4 Fahrenheit), new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, decrease or lose of sense of taste or smell, chills, headaches, unexplained fatigue, nausea/vomiting, diarrhea, abdominal pain, runny nose and or nasal congestion without other know cause.
- I confirm I am currently NOT waiting for the results of a COVID-19 test?
- If you are 70 years of age or older, I confirm I haven't experienced ANY of the following symptoms; delirium, unexplained or increased number of falls, acute functional decline and or worsening of chronic conditions.
RISKS & BENEFITS OF RECEIVING TREATMENT
- Because this virus is new there are a lot of unknowns including short and long term affects if one becomes infected. It can target different areas of the body and symptoms may be variable from person to person. Not all people will experience the same presentation and the severity of each case also presents individually. Although new precautions and regulations have been instructed by us by The College of Massage Therapist of Ontario and the Ministry of Health, we CANNOT eliminate ALL risk of becoming infected even if followed properly.
- COVID-19 is transmissible through: air droplets when a person cough, sneezes or talks, it can enter through the eyes, nose or throat if you are in close contact with an infected person and COVID-19 is known to survive on surfaces therefore the importance of disinfecting all public surfaces, thorough hand washing and social distancing (or use of PPE) have been recommended to prevent the spread.
- Although there are varying symptoms from COVID-19, the most common symptoms are; cough, runny nose, sneezing, decreased smell or taste, fever, body aches, headaches, rashes, unusual skin lesions, blood clots, and redness or discolouration of skin.
- Some people may be entirely ASYMPTOMACTIC and have NO SIGNS OR SYMPTOMS at all therefore undetected through the screening process. You still run the risk of becoming infected even with new precautions set in place. Please be mindful that incubation can be up to days. Increased occurrence of blood clotting from COVID-19 has been reported and therefore concerning in relevance to Massage Therapy. As massage increases circulation a risk of dislodging any clot and having it travel to the brain, heart or lungs is possible.
- Only clients who PASS the Government Mandated COVID-19 Screening are allowed to come in for an appointment during this time.
- I understand that if I have not successfully passed the COVID-19 Screening, my appointment will be CANCELLED.
- I agree to notify the Spa and/or cancel my appointment if there are any changes in my medical status and/or I have come in contact with a positive or suspected case of COVID-19.
- I believe that the benefits of having a massage therapy treatment today outweigh the risks involveded with receiving treatment.
- I have read the above information and fully understand the risks involved with having a massage therapy treatment today and in the future.
- I understand that new protocols have been put in place based on the College of Massage Therapist of Ontario and Ministry of Health guidelines to decrease transmission of COVID-19 and I understand that the risk CANNOT be reduced to ZERO even with all precautions taken and executed properly.
- I verify my understanding that there is still a possibility that I could come in contact with the COVID-19 virus.
I verify the information I have provided on this agreement form is truthful and accurate. I knowingly and willingly consent to receive close contact services by my Massage Therapist (Brittany A Humes RMT, CMAG) with full knowledge of the risk of contracting COVID-19 when physical distancing is not observed.
I verify my understanding that I can ask questions at any time and have them answered to my satisfaction prior to receiving treatment.
I further verify that I understand I can withdraw my consent at any time.