COVID-19 Massage Therapy Consent Form

First Name

Last Name

Date

• I understand the novel coronavirus causes the disease known as COVID-19
• I understand the novel coronavirus has a long incubation period during
which carriers of the virus may not show symptoms and still be contagious.
• All clients needed to have their temperature and oxygen level checked
before entering the treatment area.
• I confirm that I am not presenting any following symptoms of COVID-19
identified by Ontario Health Services:
- Fever>38
- Cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Difficulty swallowing
- Decrease or loss of sense the taster or smell
- Flu-like symptoms - Pink eye (Conjunctivitis)
• I confirm that I am not currently test positive for the novel coronavirus.
• I confirm that I am not waiting for test results of a laboratory test for
the novel coronavirus.
• I verify that I have not returned to Ontario from any country outside of
Canada whether by car, air, bus or train in the past 14 days
• I understand that any travel from any country outside of Canada whether by
car, air, bus or train, significantly increases my risk of contracting and
transmitting the novel coronavirus. Ontario Health Services require
self-insolation for 14 days from the date a person has returned to Canada.
• I understand that Ontario Health Services has asked individuals to
maintain social distancing of at least 2 meters (6 ft.). However, it is not
possible to maintain this distance and receive a massage treatment.
• I verify that I have not been identified as a contact of someone who has
tested positive for novel coronavirus or been asked to self-isolate by
Ontario Health, the Communicable Disease Control or any other governmental
heal agency.
• I verify the information I have provided on this form in truthful and
accurate, I knowingly and willingly consent to have a massage therapy
treatment.