Coronavirus self-declaration
Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, with their health history review, as well as with sanitation and disinfecting practices. Please complete the following and sign below.
Symptoms of COVID-19 include:
• Fever
• Fatigue
• Dry cough
• Difficulty breathing
I, ______________________________ agree to the following:
☐ 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 travelled 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 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 above statement and release the therapist and business from any and all liability for any unintentional exposure or harm due to COVID-19.
Your therapist and all employees of this clinic agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
Signature _______________________________ Date ____________________
©2020 IC Sports Therapies Pty Ltd – v3 20200505
