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Waiver Release of Liability COVID-19

Indigo has put into place preventable measures to reduce the spread of the novel COVID-19.  However, Indigo, cannot guarantee that you will not become infected with the COVID-19 virus.  Please be advised Indigo commits to a healthy business operation by providing a more heightened sanitized and disinfected environment as much as possible by reducing the numbers inside the building, increased employee PPE, and requiring sick employees to stay home, as well as other safer supportive practices.  Therefore; with each client, both established and new, we are required to obtain an updated/new client intake form which includes a health history review.  Please complete the following information, initial where applicable and sign:

I ___________________________________, agree to reveal any possible contagious nature of the COVID-19 virus listed below:

PLEASE CHECK YES OR NO

  Have you been in close contact with a confirmed case of COVID-19? YES NO

  Have you experienced a fever of 100.4 in the last 48 hours? YES NO

  Are you experiencing a cough , shortness of breath or sore throat? YES NO

  Have you had a new loss of taste or smell? YES NO

  Have you had diarrhea and/or vomiting in the last 24 hours? YES NO

  Have you had a new condition of excessive fatigue or muscle pain YES NO

  Have you suffered any “flu-like” symptoms in the past 5 (five) days? YES NO

I FURTHER ACKNOWLEDGE AND AFFIRM TO THE FOLLOWING:

  • I understand the above symptoms and affirm that I, as well as all household members, do not currently have nor have I 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, 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 service provider cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or health history provided by each client. 
  • I affirm that I will wear a mask during the entirety of my visit at Indigo.

I, __________________________________, voluntarily assume the risk and accept full responsibility that if I am exposed to or infected by COVID-19 by being present inside Indigo, located at 15 Beach Street, Woburn, Massachusetts, that I hereby agree to release my service provider, Indigo and it’s associates from any and all liability for the unintentional exposure or harm due to COVID-19.  I understand that the risk of becoming exposed to or infected by COVID-19 at Indigo may result from the actions, omissions or negligence of myself and others, including but not limited to Indigo, employees and/or associates. 

I also acknowledge that my service provider, Indigo and it’s associates agree that they themselves abide by these same standards and affirm the same.  I also acknowledge and affirm that my service provider, Indigo and it’s associates have improved and expanded sanitation and disinfecting protocols to more thoroughly fight the spread of the COVID-19 virus and other communicable conditions.

I affirm that I have carefully read this agreement and fully understand its contents.  I affirm that I have just not signed this document without reading through it in its’ entirety.  I am aware that this is a release of liability and that no one has forced me to sign this document and I affirm that I sign it of my own free will. 

Print Client Name:___________________________________________ Date:______________________

Client Signature:_____________________________________________Date:______________________

If under 18 yrs of age parent/legal guardian must sign

Print Parent/Guardian name:___________________________________Date:______________________

Parent/Guardian signature:____________________________________Date:______________________