COVID-19 Liability Waiver & Clinic ProtocolThis form must be completed prior to any service at Zen Den Medical. Please complete the form below and sign, acknowledging your understanding of our business policies and protocols to ensure your safety.Please sign and submit prior to your visit to Zen Den MedicalName First LastPhone*EmailPreferred Contact Method*PhoneTextEmailAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Acknowledgement of Business PoliciesCancellation Policy*We ask for a minimum of 24 hours advance notice to cancel your appointment or class at Zen Den Medical to allow us to offer your time to another client. We reserve the right to charge for your missed class or appointment in full.I acknowledge the cancellation policy.Refund Policy*Fees collected for classes and appointments are non-refundable. Zen Den Medical will however right any situation or circumstance outside of our cancellation policy with a gift card.I acknowledge the refund policy.Gratuities are appreciated by cash or check only.*I acknowledge the gratuity policy.Acknowledgement of Clinic PPE ProtocolPlease review and acknowledge our PPE Protocol for Clinic Clients*1. Wear a mask when you enter the building2. Please arrive no earlier than 5 minutes prior to your appointment and wait in the lobby for a clinician to greet you and take your temperature. If your temperature is 100 degrees or higher you will not be admitted.3. Limit touching of services as you navigate the building.4. Clinicians will be wearing masks.5. Only the clinician treating you will be within 6 feet of you when hands on therapy is required.6. After your session has been completed, please exit without touching anything other than the doors.7. Your card on file will be billed for the treatment.8. In between each patient we wipe down and sanitize all surfaces in the clinic with proper chemical agents as well as UV light.9. Furthermore, we wipe down the no-touch thermometer, front door, vestibule door and all around the handles (inside and out) in between each patient.ALWAYS PRACTICE SOCIAL DISTANCINGI acknowledge the clinic protocol.Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19Select to acknowledge understanding of the following statement*I understand the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.I acknowledge Zen Den and Zen Den Medical have put in place preventative measures to reduce the spread of COVID-19; however, Zen Den and Zen Den Medical cannot guarantee that I or my child(ren) will not become infected with COVID-19.Select to acknowledge the following statement*By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by patronizing Zen Den and/or Zen Den Medical and that such exposure or infection may result in personal injury, illness, permanent disability, and death.Select in understanding and acknowledgement of the risks the following statement*I understand that the risk of becoming exposed to or infected by COVID-19 at Zen Den and/or Zen Den Medical may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Zen Den and/or Zen Den Medical employees, volunteers, and program participants and their families.I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself or my child(ren) (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s patronization of Zen Den and/or Zen Den Medical (“Claims”).On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Zen Den Norwell Inc. and Zen Den Medical Inc., its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Zen Den Norwell Inc. and Zen Den Medical Inc., its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after patronization for Zen Den and/or Zen Den Medical services.Acceptance & SignatureElectronic Signature*I understand that submitting my full name in the field below constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.Signed on* Date Format: MM slash DD slash YYYYCAPTCHANameThis field is for validation purposes and should be left unchanged.
