COVID-19 Form | Acubodyworks

As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, we are monitoring the situation closely and will periodically update our guidelines based on current recommendations from the Centers for Disease Control and Prevention and the World Health Organization.

To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire prior to your arrival. Your participation is important to help us take precautionary measures to protect you and everyone in our office. Thank you for your time.

COVID-19 QUESTIONNAIRE

First Name

Last Name

Phone

Reason for this Appointment

SELF-DECLARATION BY CUSTOMER

Have you traveled to other countries within the last 14 days?

Yes

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

Yes

Have you been in close contact with anyone who has traveled to other countries within the last 14 days.

Yes

Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?

Yes

signature / Date:

By typing your name above, I hereby certify that the above statements are true and correct to the best of my knowledge. I agree to the P&C AcuMed and Bodyworks release of liabilities. The requested information is not a medical diagnosis. It is for our internal use and will not be shared.

Thanks for submitting!