I HAVE DECIDE AS A PARENT/CAREGIVER THAT MY CHILD WILL RECEIVE FACE-TO-FACE THERAPY INSTEAD OF TELETHERAPY SERVICES.
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the FLDOH and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Bilingual Key Therapy, Inc has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Bilingual Key Therapy, Inc. 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, clinic staff, and other clinic clients and their families.
I voluntarily seek services for mi child provided by Bilingual Key Therapy, Inc and acknowledge that I am increasing my child’s 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
* My child or I are 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 smell.
* My child or I have not traveled internationally within the last 14 days.
* I do not believe my child or I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* My child or I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all Florida Department of Health recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Bilingual Key Therapy, Inc harmless from, and waive on behalf of myself, my child, 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 clinic, or that may otherwise arise in any way in connection with any services received from Bilingual Key Therapy, Inc.
I understand that this release discharges Bilingual Key Therapy, Inc from any liability or claim that I, my child, or any personal representatives may have against the clinic 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 Bilingual Key Therapy.
This liability waiver and release extends to the clinic together with all owners, independent contractors, and employees.