MOBILE INTAKE & COVID WAIVER:


    PERSONAL INFORMATION:

    Date of Birth




    MEDICAL INFORMATION:

    Are you taking any medications?

    Are you currently pregnant?

    Do you suffer from chronic pain?



    Have you had any orthopedic injuries?

    Please indicate any of the following that apply to you.


    MASSAGE INFORMATION:

    Have you had a professional massage before?

    What type of massage are you seeking?

    What pressure do you prefer?

    Do you have allergies or sensitivities?


    PLEASE CIRCLE ANY AREAS OF DISCOMFORT

    COVID-19 waiver / Customer consent

    In exchange for being permitted to enter the premises of A Massage by the Sea, LLC (the
    "Business"), located at 365 N Beach RD, Unit 106, Eastsound, WA, 98245 (the "Premises") to
    receive Massage Therapy treatment (the "Activity"), I agree to the following as described in this
    contract.

    am aware that COVID affects different people in different ways, ranging from mild symptoms to
    severe illness. I confirm that I am not presenting any of the following reported conditions or
    symptoms and have no confirmed or suspected case of COVID-19, or have come in contact in
    the last 14 days with a person who has been confirmed or suspected of having COVID-19 and
    agree not to enter the Premises if I am experiencing any of the following symptoms:
    -Fever/chills
    -Shortness of Breath
    -Persistent Pain or Pressure in the Chest
    -Dry Cough/sore throat/runny nose
    -Sudden and inexplicable muscle or body aches -Nausea, vomiting, diarrhea
    -New loss of taste or smell

    I agree to have my temperature taken by my therapist immediately prior to receiving massage. I
    understand that if my temperature reads over 100.4 degrees my appointment will be cancelled
    and rescheduled for another time with no cancellation fee.

    Customer assumes the risk

    I am aware of the highly contagious nature of COVID-19 and the risk that I may be exposed to or
    contract COVID-19 by being on the Premises and engaging in the Activity.
    I acknowledge that I am voluntarily entering the Premises to engage in the Activity with
    knowledge of the danger involved. I hereby agree to accept and assume all risks of personal
    injury, illness, disability, or death related to COVID-19, arising from my being on the Premises or
    engaging in the Activity, whether caused by negligence of the Business or otherwise.
    I understand that close contact with people increases the risk of infection from COVID-19. By
    signing this form, I acknowledge that I am aware of the risks involved and give consent to
    receive massage and assume all liability in my current and future health status regarding the
    COVID-19 virus. I agree to notify A Massage by the Sea, LLC should my health status change
    after receiving massage.

    Release of Liability

    I, (the "client") knowingly and willingly consent to receiving massage therapy at A Massage by
    the Sea, LLC during the COVID-19 pandemic. I understand the risk I am taking by being a willing
    participant to receive massage in this facility today and accept all responsibility in the event I
    test positive at any time following my massage. A Massage by the Sea, LLC and all its therapists
    cannot be held liable for any exposure to the virus.
    I understand the potential risk of contracting the virus due to the long incubation period which
    carriers (A Massage by the Sea, LLC employees as well as other clients) may be asymptomatic
    and may therefore spread the virus unknowingly. I understand that the virus spreads easily from
    person to person contact.

    higher risk for contracting COVID-19:

    I fully understand that if I have any of the following conditions I am at a higher risk for
    contracting COVID-19:
    - Immunocompromised -Adult over the Age of 65 -Person with Asthma -Person with HIV
    -Person with Liver Disease
    -Hemoglobin Disorders
    -Serious Heart Conditions/Severe Obesity

    International travel: Hot spots

    I affirm that I, as well as any household members, have not traveled outside of the country or to
    any city that is considered a ‘hot spot’ for COVID-19 infections within the last 30 days. I affirm
    that I, as well as any household members, have not been diagnosed as being carriers of the
    Coronavirus, or have knowingly been exposed to anyone diagnosed with the infection.

    Governor's orders: Wearing a mask

    I agree to wear a mask while on the premises and for the entire duration of my massage
    treatment in compliance with governors orders until no longer recommended by the Washington
    State Health Department and other governing health agencies.

    Release of liability

    I hereby expressly waive and release any and all claims, now known or hereafter known, against
    the Business and its owners, employees, affiliates, and officers, on account of injury, illness,
    disability, or death arising out of or attributable to my being on the Premises or engaging in the
    Activity and being exposed to or contracting COVID-19, whether arising out of the negligence of
    the Business, its owners, employees, affiliates, officers, or otherwise.

    By signing below, you agree to the following.
    I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

    SIGNATURE:

    COVID-19 CLOSURE ANNOUNCEMENT

    Hello honored guests.

    It is in our professional opinion that the decision to continue performing massages during this outbreak is a moral one that we do not take lightly and In the best interest of your health, we will be closing our doors effective today, Dec 13th until further notice.

    We will continue to be vigilant during this time and update this page as things change.

    For up to the minute official information, please check the following link:
    https://www.governor.wa.gov/issues/issues/covid-19-resources

    Stay safe, and we will see you when our doors can safely reopen.

    Warmly,
    -Roxanne, and the team at A Massage by the Sea.