Covid19 Liability Exposure Form

Date
Pet Owner's Name

Household Symptom and Exposure Report

We at Compassionate Veterinary Hospice are doing our best to ensure the health and safety of your family, our staff, and every other family we will visit after being in your home. We appreciate your cooperation filling out this questionnaire.

Please answer the questions below.

I have answered these questions accurately and correctly to the best of my ability

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is spread mainly from person-to-person contact. Compassionate Veterinary Hospice of Chicago has put in place preventative measures to reduce the spread of COVID-19. However, we cannot guarantee that you will not contract 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 having staff enter my home and that such exposure or infection may result in personal injury, illness, permanent disability, and death. 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 having employees from Compassionate Veterinary Hospice in my home. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless the Compassionate Veterinary Hospice of Chicago, its employees, contractors, and representatives, of and from the 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 Compassionate Veterinary Hospice, its employees, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any in-home visit.
Wearing a mask (over nose and mouth) while the nurse or doctor is in your home
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