Covid-19 Pre-Visit Form | daily-calm-net

Precautionary Coronavirus Client Liability Release Form

First Name

Last Name

Phone

Due to the outbreak of the Coronavirus Daily Calm is taking extra precautions with the intake of each client, as well as sanitation and disinfecting practices. Symptoms of Covid-19 include: Fever, Fatigue, Dry Cough, or Difficulty Breathing. Please check each box below to indicate your agreement 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 within the last 30 days.

I understand that Daily Calm and it's staff cannot be held liable for any exposure to the virus or any other contagion.

By signing below, I agree to each above statement and release Daily Calm, LLC and it's staff from any and all liability for the unintentional exposure or harm due to Covid-19 and other comminicable conditions.

You may use your digital signature by typing your name above, or print this form and, either email it, or bring it with you to your appointment. Please type today's date in the field below and click "Submit Waiver" at the bottom of the page.

Thanks for submitting!

DAILY CALM WELLNESS

Massage Therapy and Detox, Non-invasive Fat Loss, and Anti-Aging Treatments

Precautionary Coronavirus Client Liability Release Form

Hours: Tues, Thurs, Fri,
10am to 7pm
Sat.
10am - 6pm

*We have a 24 hour cancellation policy.

Precautionary Coronavirus Client Liability Release Form

Hours: Tues, Thurs, Fri, 10am to 7pm Sat. 10am - 6pm

*We have a 24 hour cancellation policy.

Hours: Tues, Thurs, Fri,
10am to 7pm
Sat.
10am - 6pm