COVID19 Client Pre-Appointment Screening
Client Information 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 unfavourable outcome, which I will not be liable for. The information you provide is in confidence and will not be shared with outside parties. 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. Please complete the following and sign below. Symptoms of COVID-19 include: • Fever • Chills/Shakes • Difficulty Breathing • Dry Cough • Sore Throat • Sneezing • Skin Rashes • Sudden loss of taste or smell