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Consent and COVID-19 Agreement

I give my consent to receive bodywork and agree to the following provisions and conditions stated below:

  1. I hereby recognize and understand that Courtney Berry, LMT and/or Jordon Berry, LMT of Myo Partners, LLC (hereinafter “Practitioners”) are not; Medical Doctors, Osteopaths, Chiropractors, Naturopaths, Psychiatrists, Psychologists and that Practitioners do not hold themselves out to the public as representatives of any of any said profession;
  2. I understand that the procedures are given to help me to balance my body, mind and spirit; NOT for the treatment of medical symptoms or medical diseases/diagnoses as defined by the medical professions; I acknowledge that Practitioners do not diagnose disease, physical and/or mental disorders, prescribe drugs, or use surgery;
  3. Because bodywork should not be performed under certain medical conditions, I affirm I have stated all my known medical conditions and will keep Practitioners informed of any changes as they arise; I understand that the procedures desired are not related to the treatment of underlying organic disorders, which may exist in my person;
  4. If I experience any pain or discomfort, I will immediately inform Practitioners so that the work may be adjusted to my level of comfort;
  5. I acknowledge that I have read this entire form, have stated all my known medical conditions, and I understand and agree to the provisions described.


I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities may still recommend practicing social distancing. I further acknowledge that Courtney Berry, LMT and Jordon Berry, LMT of Myo Partners, LLC (hereinafter, “Practitioners”) have put in place preventative measures to reduce the spread of the Coronavirus/Covid-19, that I will may be in close contact with my Practitioner(s) and/or office staff and/or other clients, and that it is impossible for Practitioners to guarantee that I will not become infected with the Coronavirus/Covid-19. By signing this form, I acknowledge that I am aware of the risks involved, indemnify and hold harmless Practitioners, Myo Partners, LLC and their associates, and give consent to receive bodywork from Practitioners.

I attest that:

(1) I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell,

(2) I do not believe I have been exposed to someone with a suspected and/or confirmed case of the COVID-19,

(3) I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities,

(4) I will notify Practitioners prior to any future appointments if any of these items are not true now or at any time in the future.

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