Client & Visitor Health Screening
PLEASE FILL THIS OUT THE DAY OF YOUR APPOINTMENT. If you will be bringing a guest with you, please have your guest submit answers as well. Upon entering the center we will take your temperature and request that a face covering be worn securely over your nose and mouth. PLEASE BE CAREFUL AND RESPECTFUL by rescheduling or requesting a teleconference appointment if you or anyone in your home have ANY symptoms of Covid-19. If you are presenting symptoms in the office you may be asked to leave in order to protect our other clients, staff and their families. Thank you for your cooperation and understanding.
First Name and Last Initial
If you took your temp this morning what was the reading? (We may still take it when you arrive)
In the past 14 days have you had any of the following symptoms? Please check all that apply.
Loss of Smell/Taste
Shortness of Breath
If you answered yes to any of the above questions, please explain.
Are you experiencing any of the above symptoms today?
I'm not sure
To your knowledge have you been exposed to Covid-19 in the past 14 days?
Has anyone in your home tested positive for or was suspected to have Covid-19 in the past 30 days?
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