2020 COVID-19 Pandemic Waiver and Consent Form
I knowingly and willingly consent to services at the The Cryotherapy Place on behalf of Patient/Myself during the COVID-19 pandemic.
I Agree I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. I understand that while The Cryotherapy Place LLC, dba CryoPlace, has procedures in place in line with WHO and the CDC, there has not been any promise of a COVID free environment. And knowingly and willingly accept responsiblity for inherit risk of receiving services during the COVID-19 pandemic. I understand I should wear a protective mask over my mouth to prevent infection during participation. However, I may still be vulnerable to COVID-19 transmission while participating in services at the The Cryotherapy Place. I understand that due to the visits of members and participants, the characteristics of the virus, and the characteristics of this activity, that I may have an elevated risk to exposure. A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID.19. I have disclosed any condition that compromises my immune system and understand that I may be asked toconsider rescheduling this activity after discussing any such conditions with the The Cryotherapy Place staff.
It is also important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus. I attest that I do not have a fever or above normal temperature. I attest that I am not experiencing shortness of breath or had trouble breathing. I do not have a dry cough? I do not have a runny nose? I have not tested positive for COVID -19 nor been knowingly exposed to anyone that has tested postiive. I have not recently lost or had a reduction in my sense of smell I do not have a sore throat? I am not awaiting results to COVID-19 test results. I have not traveled outside the United States by air or cruise ship in the past 14 days. I have not traveled within the United States by air, bus or train within the past 14 days.
By signing below in both my individual capacity and as Parent/Guardian, if applicable, I represent that I have fully read and understood the provisions above, have had the opportunity to ask questions about any of the above, and that I accept the associated risk to myself and to minor