Safety Protocol, Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus (COVID-19) has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and other measures to attempt to limit the spread of infection.
In response, Greta Jane, has put in place the following preventative measures to reduce the spread of COVID-19 for in-person sessions with clients:
Monitoring my own contact with others and ensuring, to the best of my ability, that I have had no contact with anyone who has tested positive for COVID-19 in the past 14 days.
Testing myself every two weeks for active COVID-19 infection.
On the day of your visit, tracking my temperature and making sure I am showing no signs of COVID-19 infection (dry cough, shortness of breath, difficulty breathing).
Washing my hands thoroughly before and between all in-person client sessions.
Sanitizing all touch points such as door knobs, bathroom fixtures, and changing sheets and pillowcases between clients.
Requiring that clients wear masks.
Requesting that you sanitize your hands upon entry into my office room.
Requesting that you not bring in any bags, purses or personal items that are not necessary for your session.
Greeting clients at the door and going through an entry protocol checklist.
Despite best efforts, however, I cannot guarantee that you will not become infected with COVID-19 from exposure at an in-person session in my office and I want to acknowledge that in-person sessions could increase your risk of contracting COVID-19.
By signing this agreement, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you may be exposed to or infected by COVID-19 by attending in-person sessions with me and that such exposure or infection may result in personal injury, illness, permanent disability, and death. You understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of Sacred Womb Services or others who use my office space.
Assumption of Risk
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my in-person treatment withGreta Jane. On my behalf, and on behalf of my heirs and assigns, I hereby release, covenant not to sue, discharge, and hold harmless the practitioner, their employees, members, agents, and representatives, of and from all claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to exposure to or infection with COVID-19. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the practitioner, their employees, members, agents, and representatives, whether a COVID-19 infection occurs before, during, or after in-person treatment with the practitioner.
Consent for Contact Tracing
I understand that Greta Jane will provide my contact info to applicable health departments for contact tracing should one of their clients test positive for COVID-19 within a 14-day period before my visit. I also agree to provide contact info of Sacred Womb Services if I have a positive test for COVID-19 within 14 days after my in-person session.
Signature of Client/Student:______________________________________________________________
Print Name of Client/Student:_______________________________________________ Date:_________