Time For Me Massage- Precautionary Coronavirus (COVID-19) Liability Release Form
Symptoms of COVID-19 include:
• Dry cough • Chills
• Shortness of breath/difficulty breathing • Fatigue
• Fever • Sore throat
• Muscle/body aches • New loss of taste or smell
Please read the following statements:
• 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 who has been
diagnosed with COVID-19 within the last 30 days.
• I affirm that I, as well as all household members, have not travelled outside of the country or to any U.S. city
that is or has been considered a “hot spot” for COVID-19 within the last 30 days.
• I understand that 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.
By signing below, I agree to each of the above statements and release my massage therapist and business from any and
all liability for the unintentional exposure of COVID-19.
Your massage therapist agrees that they abide by these same standards and affirm the same.
Signature: ______________________________________________________ Date: ____________________________
Symptoms of COVID-19 include:
• Dry cough • Chills
• Shortness of breath/difficulty breathing • Fatigue
• Fever • Sore throat
• Muscle/body aches • New loss of taste or smell
Please read the following statements:
• 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 who has been
diagnosed with COVID-19 within the last 30 days.
• I affirm that I, as well as all household members, have not travelled outside of the country or to any U.S. city
that is or has been considered a “hot spot” for COVID-19 within the last 30 days.
• I understand that 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.
By signing below, I agree to each of the above statements and release my massage therapist and business from any and
all liability for the unintentional exposure of COVID-19.
Your massage therapist agrees that they abide by these same standards and affirm the same.
Signature: ______________________________________________________ Date: ____________________________
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