COVID-19 Liability Waiver - Staff Requested


Client Name:  
Client Date of Birth:    
Person signing this form is the:    
Name of person signing this form:   

I attest that:

  • 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
  • I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
  • I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health
  • I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
  • I have not traveled internationally within the last 14
  • I have not traveled to a highly impacted area within the United States of America in the last 14 days. If so, please tell us where you traveled to and your dates of travel.

I acknowledge the following:

  • The contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social
  • Minnesota CarePartner, LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
  • Minnesota CarePartner, 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, counseling staff, and other clients and their families.
  • I voluntarily seek services provided by Minnesota CarePartner, LLC and understand that I am increasing my risk to exposure to the Coronavirus/COVID-19.
  • I will comply with all set procedures to reduce the spread while attending my appointment.

I hereby release and agree to hold Minnesota CarePartner, LLC harmless from, and waive on behalf of myself 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 counseling practice, or that may otherwise arise in any way in connection with any services received from Minnesota CarePartner, LLC. I understand that this release discharges Minnesota CarePartner, LLC from any liability or claim that I, my heirs, or any personal representatives may have against the practice 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 Minnesota CarePartner, LLC. This liability waiver and release extends to the counseling practice together with all therapists and other employees.

By signing this document, I accept the terms and acknowledge the risk as stated above.

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Signature Certificate
Document name: COVID-19 Liability Waiver - Staff Requested
lock iconUnique Document ID: 5e1562feb01b6abb115cf8f2a02a95cf9d953451
Timestamp Audit
October 13, 2020 9:47 am CDTCOVID-19 Liability Waiver - Staff Requested Uploaded by Roots Recovery - IP
December 17, 2020 11:38 am CDTMNCP Info - added by Roots Recovery - as a CC'd Recipient Ip: