COVID Waiver Form
NYC PSYCHOLOGY INC., PC
Manhattan | Brooklyn | Rockland County | Great Neck
646-837-5557 | email@example.com
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Center for Anxiety LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Center for Anxiety LLC cannot guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families.
I voluntarily seek services provided by Center for Anxiety LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not currently experiencing, or have recently experienced (in the last 48 hours), any new or worsening COVID-19 symptoms.
* I have not had close contact (being within six feet for at least 10 minutes over a 24-hour period) or proximate contact (as determined by health authorities) in the past 10 days with any person confirmed by diagnostic test, or suspected based on symptoms, to have COVID-19.
* I have not tested positive through a diagnostic test for COVID-19 in the past 10 days.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Center for Anxiety LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the center, or that may otherwise arise in any way in connection with any services received from Center for Anxiety LLC. I understand that this release discharges Center for Anxiety LLC from any liability or claim that I, my heirs, or any personal representatives may have against the center with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Center for Anxiety LLC. This liability waiver and release extends to Center for Anxiety together with all owners, partners, employees, and associated entities, including NYC Psychology PC.