Back 2 Normal COVID-19 CONSENT FORM

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out the following consent for service. All fields are required.

Email *

First & Last Name *

Date of Birth *

I knowingly and willingly consent to have physical therapy, performance, or wellness treatments despite the COVID-19 and social distancing climate. *

I consent.

Required

I understand the COVID-19 virus has a long incubation period during which carriers of the virus are asymptomatic. Our determination to service clients is based on present health conditions. *

I consent.

Required

I understand that the inability for both myself and my therapist to be socially distanced during my appointments puts me at risk for person-to-person transmission and as an alternative, Telehealth sessions are available for physical therapy, performance, or wellness sessions. *

I consent.

Required

Please select if you or any member of your household are presenting any of the following COVID-19 symptoms listed below: *

Cough

Shortness of breath or difficulty breathing

Fever above 100.4° temp

Chills

Muscle pain

New loss of taste or smell

Sore throat

Nausea

Vomitting

Excessive fatigue or lethargy

None of the above

I understand that air travel significantly increases the risk of contracting and transmitting the COVID-19 virus. And I understand that the CDC, OSHA, and Florida Department of Business and Professional Regulation recommend social distancing of at least 6 feet. *

I acknowledge and understand.

Required

I verify that I have not traveled outside the United States in the past 14 days. *

I verify.

I do not verify.

Required

I understand that Back 2 Normal Physical Therapy is NOT responsible for the exposure I may encounter via clients and staff. I will abide by CDC guidelines including handwashing, face coverings, and all other safety procedures set by Back 2 Normal Physical Therapy. *

I consent.

Required

I agree to inform Back 2 Normal Physical Therapy of any changes in my health including any COVID-19 symptoms or inability to social distance that may affect the safety of others before attending any therapy or training sessions at Back 2 Normal Physical Therapy. *

I verify.

I do not verify.

Required

Today's Date *

YYYY

Retype Name to "Sign" *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms