Provider Covid-19 Screening Form
The State of NY mandates that providers must complete a health screening assessment DAILY before they are allowed to see their scheduled patients. Please complete the below questionnaire. Thank you.
*
Is your temperature today under 100.5 degrees?
Clear selection
Have you tested positive for Covid-19 through a diagnostic test in the past 14 days? *
Have you experienced any of the following COVID-19 symptoms in past 14 days? *
Required
Have you knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of Covid-19? *
If you have traveled outside of NYS or outside a state that shares a border with NY within the past 14 days, have you tested negative for Covid-19?
Clear selection
I have brought my own clean required PPE today and/or I have access to the required PPE to treat my clients today. *
I confirm that the information given in this form is true, complete and accurate. I agree to follow all NYS Guidelines regarding Massage Therapy and agree to abide by the Hand in Health NY Forward Safety Plan. I understand that any misrepresentation, falsification, or omission of any facts may result in cancellation of your Provider Agreement. *
Required
Submit
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