Covid-19 Form | BodyworkWithJ

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Jay Sheffield, LMT

Somatic Support for Individuals & Organizations

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COVID-19 WAIVER

Step one: read the entire Covid-19 section on the logistics page.

First Name (Use one on Vaccine Card, if applicable.)

Last Name

# of Vaccinations: *

I will cancel my appoinment if I have any symptoms associated with COVID-19 or a common cold/flu. *

Yes

I will cancel my appoinment if I test positive for COVID-19.^ *

Yes

I will text J if I am exposed in the days leading up to my appt. *

Yes

^See "When to Cancel" under Covid-19 protocol on the logistics page for info on when you can re-book.

Initials

Date

I HAVE READ THE ENTIRE COVID-19 SECTION ON THE LOGISTICS PAGE AND I declare that the info I’ve provided is accurate & complete and I do not hold J Sheffield/Bodywork With J liable for any risks or results associated with receiving bodywork during the COVID-19 pandemic. I knowingly and willfully consent to treatment and accept all associated risks as my own.

Next Step: Email an image of your most current vaccination card to bodyworkwithj@gmail, if applicable. If you aren't vaccinated, email me to discuss if we can still work together.

Thanks for submitting!
Next Step: Email an image of your most current vaccination card to bodyworkwithj@gmail.com

J Sheffield

bodyworkwithj@gmail.com

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