Physical Therapy To Go, PLLC COVID-19 Attestation Form

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You and ALL MEMBERS in your home at the time of your scheduled Physical Therapy visit must complete this form before your scheduled Physical Therapy Appointment can begin. Thank you for your cooperation and keeping our therapists and fellow New Yorkers SAFE

Full Name *

Appointment Date *

YYYY

Time

I Am a... *

I understand that I will wash my hands and wear a mask upon the Physical Therapist's arrival

Yes

I have questions

Please select any and all of the following which you have experienced in the past 14 days: *

1. COVID-19 Symptoms: dry cough; chills; sore throat; fever; headache; body aches; loss of taste or smell.

2. COVID-19 test with pending results (please wait until results are known).

3. Tested positive for COVID-19.

4. Exposure to someone with a known or suspected case of COVID-19.

5. I have NOT experienced any of the following symptoms or situations.

If you have experienced any of options 1-4, please do not have the Physical Therapist come to your home **late cancellation fees will be waived in these cases

I have read each symptom and circumstance above and confirm that I have NOT experienced any of the symptoms or situations: * *

Yes, I confirm

No, I cannot confirm

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