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.
Have you been exposed to COVID-19 or do you believe that you have?
If yes, please list date(s) of exposure.
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)
Loss of taste or smell
Sudden onset of diarrhea
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:
Thank you for your continued trust in our practice.
As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.
Despite our careful attention to disinfection, social distancing, and use of face masks, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, home of a relative, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the services we provide, it is not possible to maintain social distancing between the patient, doctor/therapist, staff and in rare cases other patients at all times.
Although exposure is unlikely, do you accept the risk and consent to treatment?
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.
Never submit passwords through Google Forms.
This form was created inside of Two Cans Media.