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Outback Physical Therapy - COVID19 attestation
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Please indicate today’s date *
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Within the last 48 hours have you had any of the following symptoms? *
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Within the last 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who has tested positive for COVID-19 or symptoms consistent with COVID-19? *
Are you isolating for any reason including waiting on the results of a COVID-19 test? *
Within the last 14 days have you been in any of the COVID-10 high risk states?   (For list of exempt states click https://www.mass.gov/info-details/covid-19-travel-order#lower-risk-states- ) *
By typing my full name below I attest that all information provided is true *
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