Pre-Appointment Covid-19 Screening
KNOSIS Physiotherapy & Wellness
212.906.4440
info@knosiswellness.com



In our effort to keep everyone safe, we ask that you complete and submit this brief Screening Form before you arrive for each appointment.
Last Name *
Have you traveled to any state outside of NJ, CT, VT, MA or to a Level 2 or 3 country in the past 14 days? *
If you did not quarantine for 14 days upon return from travel, have you quarantined for 3 days and tested negative for COVID-19 on the 4th day? *
Have you been diagnosed with or been exposed (within 6 feet for more than 15 min) to someone diagnosed with COVID-19 in the past 14 days? *
Have you been exposed to anyone who has been asked to quarantine after a possible exposure in the past 14 days? *
Have you experienced or been exposed to someone who has experienced symptoms of oncoming illness including congestion, cough, fever, loss of taste/smell or shortness of breath in the past 14 days? *
For your safety as well as ours, we ask if you develop any symptoms of Covid-19 after or between appointments that you notify our office at 212.906.4440 *
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