Mandatory COVID-19 Screening
To keep all parties involved as safe as possible, please fill out this quick survey at least 24 hours BEFORE your appointment. You are coming for a routine appointment, which will take place during the COVID-19 pandemic. By completing this form, you acknowledge the following: While I am in compliance with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, I cannot make any guarantee of a COVID-19 free environment. I am symptom-free and have not been exposed to the best of my knowledge. However, since this is a place of public accommodation, other persons (including other clients) could be infected, with or without their knowledge. In order to reduce the risk of the spread of COVID-19, please answer all screening questions below. For the safety of everyone, please be truthful and candid in your answers.
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1. Name *
2. Appointment Date *
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DD
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3. Email *
4. What are your treatment goals for this session? Are there any specific areas of the body that you would like addressed? *
5. Currently or at any time in the last 48 hours, have you had a temperature of 100.4 or greater? *
6. Do you have any of the following signs or symptoms? *
Required
7. Have you tested positive for COVID-19 in the last 14 days and/or are you under self-quarantine orders from your doctor? *
8. Have you had close contact with a confirmed or probable/suspected case of COVID-19 within the last 14 days? *
Rescheduling Procedures:
If you have answered "yes" to questions 5, 6, 7 or 8 you will need to reschedule your appointment.
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