• Covid Health Questionnaire & Informed Consent

    Physical Therapy Treatment in the Era of COVID-19

  • Anniel Nagler, MSPT
    Pediatric Physical Therapist
    Phone: (954) 648-7819
    Fax: (954) 231-0799

  • FUNdamental Therapy Inc
    4106 North 48th Avenue
    Hollywood FL 33021
    anniel@funtherapyinc.com

  • If you have been exposed to a communicable disease, you may spread the disease to the physical therapist, physical therapist family, or other children/families in which I also see for physical therapy treatments. Therefore, prior to each appointment I will need the parent/guardian to complete the following questions to reduce the chances of transmission:

    Do you, your child, others present in your home during your child’s appointment, or anyone you have recently been in contact with, knowingly have any of the following symptoms?

  • Fever (defined as above 100.4 degrees)?*
  • Cough?*
  • Shortness of breath and/or trouble breathing?*
  • Persistent pain, pressure, or tightness in the chest?*
  • Have you, your child, others living in your home or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*
  • If yes, provide approximate dates of illness:*

  • Agreement to Receive In-Person Pediatric Physical Therapy Services During COVID-19

    Physical Therapy Treatment in the Era of COVID-19
    1. It is possible that I or my child(ren), may be exposed to and/or contract COVID-19 and Fundamental Therapy Inc. and my therapist(s) are not to be held liable.
    2. My therapist(s) works in many different homes, offices, and counties throughout the week and therefore, may have an increased risk of exposure to COVID-19.
    3. I will confirm my appointment with my therapist as well as answer screening questions asked of me to the best of my knowledge, prior to my therapist entering my home. I will be forthright with Fundamental Therapy Inc. if we have been exposed or are experiencing symptoms of COVID-19. If I answer “yes” to any of the screening questions, our session may happen via teleintervention in lieu of face to face to keep everyone safe.
  • Although exposure is unlikely, do you accept the risk and consent to treatment?
  • Birthdate:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Parent's eSignature:*
  • Date:*
     . .
    4 digit year, 2 digit month, 2 digit day
  • Time:*
  • Should be Empty: