Covid-19 Release Form

Due to the situation with the novel Coronavirus I am taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Symptoms of COVID-19 include: - Fever - Fatigue - Dry cough - Difficulty breathing.

Please read the following and sign below.

• 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 last 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 last 30 days.

• I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.

• I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

Please initial to accept and agree the above.

I, as your massage therapist, will abide and respect the same standards. I have improved and expanded my sanitation protocols to fight the spread of COVID-19 and other communicable conditions.

Petaluma Family Chiropractic

Citrine

Gift Certificates : : Covid Info & Forms