Covid-19 Screening
Please complete this form prior to attending the facility.
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Given Name *
Surname *
Date of Session *
MM
/
DD
/
YYYY
Time of Session *
Time
:
If you answer Yes to any of the following questions, please reschedule your appointment. *
Yes
No
Have you been diagnosed with Covid-19 in the past 14 days?
Have you been in contact with anyone that has been diagnosed with Covid-19 in the past 14 days?
In the past 14 days have you experienced any of the following symptoms: shortness of breath, fever, dry cough, loss of taste or smell.
Note: If you feel unwell in any way, please reschedule your session.
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