COVID-19 HEALTH FORM | touchofgoodkarma

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

I have NOT had a fever in the last 2 weeks equal to 100.4 degrees or higher.

I have NOT had any respiratory or flu symptoms, sore throat, or shortness of breath in the last 2 weeks.

I have NOT been in contact with anyone suspected or diagnosed with Covid-19 or any of the syptoms in the last 2 weeks.

I agree to follow saftey guidelines by wearing a mask, saintizing hands frequently, and understand that the therapist is required to follow the same guidelines.

Full Name

Date

I declare that the info I’ve provided is accurate & complete.

Thank you for submitting! If you left any of the boxes unchecked, we would ask that you please reschedule your appointment until after speaking with your Physician or receiving a negative Covid-19 Screening Test.