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By completing this form I authorize The Pacific Clinic to use and disclose the protected health information described in this assessment to their medical director and necessary team members to aid in my treatment and care at the facility.

This authorization for release of this information covers the period of

all past, present, and future periods.

Pacific Clinic assessment form is used to determine the necessity of functional exercise and activities for the physical, emotional and mental well-being of clients. COMPLETING THIS FORM DOES NOT AUTOMATICALLY ENROLL YOU IN A WELLNESS PLAN. PLEASE CALL 509-783-5465 TO SCHEDULE AN APPOINTMENT TO GET ENROLLED.


The health and safety of our members, guests and employees is a top priority for the Clinic.

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, local governments and health agencies recommend social distancing and, in some cases, prohibit the congregation of large groups of people.

Pacific Clinic (“the Clinic”) has put in place preventative measures to reduce the spread of COVID-19; however, the Clinic cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Clinic could increase your risk and your child(ren)’s risk of contracting COVID-19. The Pacific Clinic follows CDC (Center for Disease control) guidelines of social distancing and sanitation for the protection of all people who enter our facility.

If I have any of the following, I understand I am not allowed to enter the facility and I agree to abide by these expectations:

  • If I have been diagnosed with COVID-19 and have not recovered or am still within the required 5-day isolation.

  • If I had symptoms of COVID-19 within the last 24 hours. Or if I experience the following: a fever, cough, shortness of breath, sore throat, loss of taste or smell, vomiting or diarrhea or any other symptoms, I will stay home.

  • If I had contact with a person who has or is suspected to have COVID-19 within the last 14 days.

  • I agree to not enter the facility if I am sick. I will cover my cough or sneeze with a tissue and wash my hands. I will not touch my eyes, nose, or mouth and will practice good hygiene.

  • I will abide by social distancing – stay at least 6 feet away from other people.• I will wear a face covering as required by the State mandates this is subject to change as we move out of the various phases.

  • I agree to wash my hands upon entrance to the Clinic (if mandated) and frequently with soap and water for at least 20 seconds. Or use hand sanitizer.

  • I agree to wipe off equipment before and after each use.

By submitting the form below I am agreeing to the above statements and I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Clinic and that such exposure or infection may result in personal injury, illness, permanent disability, and / or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Clinic may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Clinic employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (or illness) to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Clinic or my participation in Clinic programming (“Claims”). On behalf of me and my children, I hereby release, covenant not to sue, discharge, and hold harmless the Clinic, its owners, employees, agents, 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 Clinic, its owners or employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after my participation in any Clinic usage, lesson, class, or program.

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