Consent Form for Registered Massage Therapy Treatments
COVID-19 Patient Intake Consent Form
Patient name (please print): _______________________________________________________________
1. Yes ___ No ___ Do you currently have a fever, chills, a new cough, a worsening chronic cough,
shortness of breath, or difficulty breathing?
2. Yes ___ No ___ Have you or a member of your household traveled outside of Canada in the past
3. Yes ___ No ___ Do you have a confirmed case of COVID-19 or have a member of your household with a confirmed case of COVID-19?
4. Yes ___ No ___ Do you or have you had 2 or more of the following symptoms in the past 14 days: sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing,
decreased or loss of smell and/or taste, chills, fever, diarrhea, abdominal pain, or fatigue/malaise?
* If you answered yes to any of the above questions please reschedule your appointment. *
I acknowledge and confirm, to the best of my ability, that the above information is true.
Signed: ______________________________________ Date: ___________________________________
I understand that while Kelly Pearce, RMT, and Mountain Vista Health Centre have taken measures to minimize the risk of viral transmission, the nature of massage therapy means that physical distancing is not possible in the treatment room and that risk cannot be reduced to zero. I understand that by receiving massage therapy there is the possibility of contracting a viral illness such as COVD-19.
I acknowledge that I have been offered the choice to bring personal protective equipment (PPE) such as a face mask to wear during my consultation and treatment and that I have also been offered a face mask to use. I acknowledge that I have been given the choice to have Kelly Pearce, RMT wears a face mask and/ or gloves during my consultation and treatment.
Despite there being a risk of contracting a viral illness by receiving massage therapy I consent to treatment. By signing this consent form I release my therapist, Kelly Pearce, RMT, from any and all liability should I contract or be exposed to COVID-19 at this clinic.
Patient Signature: Date: