COVID-19 In-Person Services Consent Form - Music Therapy Connections

Your name*
First Last
Family member receiving services (if applicable)
First Last
Family member receiving services (if applicable)
First Last
Initial here*
I knowingly and willingly consent for myself or my family member(s) to receive face-to-face services at Music Therapy Connections during the COVID-19 pandemic. 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 have been made aware of the CDC guidelines that MTC will be operating under during the current pandemic and agree to comply with infection control protocols including but not limited to: universal masking, handwashing, and social/physical distancing.
Initial here*
I confirm that I/my family is not presenting any of the following symptoms of COVID-19 listed below:

Fever
Shortness of Breath
Loss of Sense of Taste or Smell
Dry Cough
Runny Nose
Sore Throat
Nausea/Vomiting/Diarrhea
Consent*
I confirm that all of the above statements are true, and consent for myself and/or family member(s) to receive face-to-face services at Music Therapy Connections.