Lander Chiropractic COVID-19 Pre-Visit Screening Survey
As essential healthcare workers, LANDER CHIROPRACTIC has been able to continue to serve our community with necessary chiropractic care. As such, we must do everything possible to mitigate risk to our staff and other members of the community so it is vitally important to you complete this form accurate prior to each visit.
First and Last Name
Have you been exposed to COVID-19 or do you believe that you have?
Please check any of the following symptoms you (or other members of your family that also have an appointment) are currently expressing:
Shortness of breath
Severe fatigue (not related with travel)
None of the above
Have you traveled to or from a high-risk geographic area in the past 14 days?
If you are visiting LANDER CHIROPRACTIC with other family members, please list their names and which symptoms listed above (if any) they are currently experiencing:
By typing in your name and the date in the field below, you are attesting that everything you stated above is truthful and accurate to the best of your knowledge.
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This form was created inside of Two Cans Media.