Consent and Release of Liability, Waiver of all Possible Claims and Assumption of Risk
**Please review before signing**
Acknowledgment of Risks
Despite the measures that have been implemented to date, there is still a general, inherent risk of individuals contracting COVID-19.
I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending at the Facility. I also acknowledge and accept that while receiving services, the HCP may need to be closer than the recommended social distancing guidelines (less than 2 meters) in order to assess and/or treat me.
Consent to Treatment
In consideration of Maryla Podgajny (PT) HCP, agreeing to see me in person at the Facility, I agree to release Maryla Podgajny at On The Coast Physio and the Facility, their officers, directors, employees, agents and volunteers (the “Releasees”) from any and all causes of action, claims, demands, requests, damages or any recourse whatsoever in respect of any personal injuries or other damages which may occur or arise as a result of exposure to COVID-19 during my visit to On The Coast Physio and/or through the provision of services to me by the HCP.
I do hereby acknowledge and agree that notwithstanding the generality of the foregoing, I declare that I will not commence litigation or otherwise seek to recover damages or other compensation against the Releasees based on any action, claim, demand, request, loss or any recourse whatsoever arising from any potential or actual exposure to COVID-19 while attending at the Facility and/or through the provision of services to me by the HCP. I further acknowledge that the Releasees can rely on this Release of Liability, Waiver of all Possible Claims and Assumption of Risk as a complete defence to any and all claims, damages, causes of action, or recourse or liability that may arise at any time.
COVID-19 Contact Tracing
In case a COVID-19 exposure occurs in the clinic, the Public Health Authority will need access to personal information for all persons who have entered the clinic. You agree to have your personal information shared with the Public Health Authority upon request for contact tracing purposes only.