COVID-19 Liability Screening | Integrative Animal Hospital of Central Florida

Integrative Animal Hospital of Central Florida has put in place preventative measures to reduce the spread of COVID-19; however, the Practice cannot guarantee that you will not become infected with COVID-19 or that you are not already an asymptomatic carrier of COVID-19. Further, receiving services at this Practice could increase your risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving services at the Practice and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Practice may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Practice owners and employees. In consideration for being permitted to receive services at the Practice, I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with receiving services at the Practice. On my behalf, and on behalf of my heirs, executors, administrators, personal representatives, and assigns, I hereby release, covenant not to sue, discharge, and hold harmless the Practice, its employees, agents, and representatives, of and from any claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the Practice, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after receiving services at the Practice.

Your Full Name: *

Pet Name: *

Are you currently awaiting the results of a COVID-19 test? *

Yes

Have you had the COVID-19 vaccination? *

Yes

Do you currently have any of the following symptoms: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100.4 degrees Fahrenheit? *

Yes

Have you traveled outside the country in the last 14 days? *

Yes

Date: *

Monday	7:00 am	7:00 pm
Tuesday	7:00 am	7:00 pm
Wednesday	7:00 am	7:00 pm
Thursday	7:00 am	7:00 pm
Friday	7:00 am	7:00 pm
Saturday	8:00 am	1:00 pm
Sunday	Closed	Closed