Declaration of Health and Liability Release
Your Private Health Information (PHI) is important and information submitted via this form to Relief Therapy - Christopher Pierce ("Christopher", "Chris", "I", "me") is protected under HIPAA with a BAA via Google Services. What this means is that PHI submitted in this form is kept private according to regulations under HIPAA. For more specific information and questions contact cpierce@relieftherapychicago.com or refer to https://support.google.com/a/answer/3407054.
By typing my full name below, I verify that on this date I do not have, to the best of my knowledge, any condition which could be spread during the normal course of massage or close contact, nor am I experiencing fever, chills, shortness of breath, or cough. I also release Christopher, and any companies he associates with, from liability associated with potential exposure to diseases or infections during my appointment. *
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