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SCREENING FORM

Please complete our COVID-19 Screening and Consent to Treat Form: 

This form is required to be completed no more than 24-hours and by 6pm the day before your scheduled appointment or your appointment will be cancelled!

Have you had a fever in the last 24 hours of 100.4 F or above?*
Have you experienced any of the following COVID-19 symptoms in the past 14 days?*
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*
Have you traveled outside of New York State in the last 14 Days?*
I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department*
I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner. *
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Thank you! Your COVID-19 screening form was sent successfully.