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.
* Required
Last Name
*
Your answer
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?
*
Yes - If your have traveled out of the country in the last 14 days please call our office before your next appointment.
No
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?
*
Yes
No
I have not traveled in over 14 days outside of NY, NJ, CT, VT or MA
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?
*
Yes - If yes, please call our office before your next appointment.
No
Have you been exposed to anyone who has been asked to quarantine after a possible exposure in the past 14 days?
*
Yes - If yes, please call our office before your next appointment.
No
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?
*
Yes - If yes, please call our office before your next appointment.
No
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
*
I agree to notify KNOSIS if I develop any symptoms of Covid-19
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