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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2. Appointment Date
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?
New onset of cough
Shortness of breath or difficulty breathing
New loss of sense of taste or smell
Nausea/vomiting or diarrhea
None of the above
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?
If you have answered "yes" to questions 5, 6, 7 or 8 you will need to reschedule your appointment.
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