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                Precautionary Covid-19 Liability Release Form                  

**Required Prior to Every Scheduled Appointment or Attendance in Class or Workshop

Here at Long Island Healing Arts & Learning Center we are now taking extra precautions to protect our

shoppers, visitors, clients and workshop/class attendees by implementing additional sanitation and disinfection practices.

We will be practicing social distancing as well as requiring that all in the center wear masks.                    

Please complete the following form before any scheduled appointment or attendance  of any class/workshop and sign below.

Possible symptoms of COVID-19 include:

  • Cough

  • Shortness of breath or difficulty breathing

  • Fever

  • Chills

  • Muscle pain

  • Sore throat

  • Loss of smell or taste

  • Runny nose

  • Flu-like symptoms



I agree to the following: *

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. 


I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.  


I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.  


I understand that Long Island Healing Arts & Learning Center and all associated with the Center cannot be held liable for any exposure to the COVID-19 virus as I have decided to come here on my own free will.

I understand that:

Physical distancing of 6 ft. may not always be possible while receiving energy services or attending a workshop/class.
I must sanitize my hands before entering the Treatment Rooms or Workshop Room
I must make all attempts to cover my mouth and nose in the event of coughing and/or sneezing and then immediately sterilize my hands
I will minimize the touching of common surface/areas
I may NOT bring children into the Center.
I understand the staff of the LI Healing Arts Center will do everything possible to minimize the spread of COVID-19, but will not hold them responsible should I contract COVID-19.

I confirm that:

I am not currently positive for COVID-19
I am not waiting for the results of a laboratory test for COVID-19
I have not returned to the United States from any other State or Country, whether by car, air, sea,

bus or train in the past 14 days
I have not been identified as a contact of someone who has test positive for COVID-19 or been asked

to self-isolate by any government agency.


By signing below, I agree to each statement above and release Long Island Healing Arts & Learning Center

from any and all liability for the unintentional exposure or harm due to COVID-19.

Long Island Healing Arts & Learning Center’s Owners and Associates agree to abide by these standards

and affirm the same.




PRINT NAME____________________________________________________________________________________DATE_________

PHONE________________________________________________ EMAIL_________________________________________________

ADDRESS _________________________________________________________________________________ZIP_________________



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