Please take the time to read everything below before answering.

Here at Jeevam Therapy, we care for our and our-patients' safety.
In order to keep everyone as safe as possible, we are requiring all patients to fill out this survey before each in-person. This survey will be sent via text 24hr in advance. Please fill out the form at least 6hrs prior to the given appointment time.

Please take your time to answer truthfully. If you answer YES to any question, please do not come to your appointment, wait for our call and discussion. We may ask you to self-quarantine for 14 days, and take a COVID-19 test before returning to physical therapy.

If any of your answers have changed anytime before your appointment please re-submit the survey using the same link provided. By doing so, the last-minute cancellation fee will be waived.

We also are happy to accommodate you by rescheduling your appointment after the 14 days or after submitting a negative COVID-19 test to us via text or fax to 732-515-7868.

Once the survey has been completed you are certifying that the answers below are true.
Failure to answer truthfully or withholding information intentionally will lead to immediate dismissal from our practice and may be subject to applicable laws during this pandemic.

** To maintain a safe distance we encourage you to text or call us once you have arrived. Please wait outside the clinic door or in your car until we respond. **

** To ensure safety: everyone is REQUIRED to wear a mask**

**Please note: during the patients' session, all parents or guardians MUST stay in the waiting room area or in their cars with the exception of the Initial evaluation or if needed to speak with the Doctor***

** Please be aware that falsifying data on this form may subject to legal action for public endangerment***


Thank you