Covid-19 Acknowledgement

Contractor Name

First NameLast Name

By checking the boxes, you confirm that you agree with the following statements:

Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell

Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or get infected?

Are you living with anyone that is infected or quarantined due to COVID-19?

I agree not to enter our office for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

Your Name

First NameLast Name

Date

Your Signature

Covid-19 Acknowledgement Form