Covid-19 Repeat Appointment Screening
Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, healthy history review, as well as increased sanitation and disinfecting practices.
Symptoms of COVID-19 include:
– Difficulty Breathing
– Dry Cough
– Sore Throat
– Skin Rashes
– Sudden loss of taste or smell
Please be honest when filling out this form. If you do not fully disclose information asked, any services I may provide based on the information you give me could result in an unfavorable outcome, which I will not be liable for. The information you provide is in confidence and will not be shared with outside parties. If you have any hesitation towards coming in to your appointment, please reschedule.
Please complete the following and sign below. Services will not be provided unless this form is completed in full and submitted.
If you are unsure if your answers from the original document are the same, or if you wish to review the original form please click here. If there have been no changes please complete the below form.