Covid-19 Release & Liability Form

Name *

First Name

Last Name

Symptoms *

Please check every symptom you've experienced in the last 14 days:

sore throat

cough

chills

body aches for unknown reasons

shortness of breath for unknown reasons

loss of smell

loss of taste

fever at or greater than 100 degrees Fahrenheit

none of these

Have you or anyone in your household tested positive for COVID-19? *

Yes

No

If you answered yes to the previous question, are you currently in quarantine? *

Yes

No

Have you or anyone in your household traveled outside the state in the last 14 days? *

Yes

No

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? *

Yes

No

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

Yes

No

I assume the risk of contracting Covid 19 while receiving treatment from Amanda and hereby Release Amanda from any claim of injury or damages should I contract Covid19 from Amanda *

Yes

Please type your name to stand as your signature: *

First Name

Last Name

Please type today's date: *

MM

DD

YYYY