RINNOVO COVID WELLNESS FORM

RINNOVO Wellness Form

Your safety is our priority.

We will be screening all of our staff members and clients for signs of COVID-19 virus.

Please answer the questions below. We appreciate your honesty.

Name *

First Name Last Name

Phone Number: *

Email: *

Do you have a cough? *

Do you have a fever now, or have you had a fever in the past 72 hours/3 Days? *

Are you experiencing any cold/flu like symptoms such as cough, shortness of breath or fever? *

Have you traveled outside of the United States in the last 2 weeks? *

Have you traveled outside of the Country in the last 2 months? *

Have you come in contact with someone experiencing symptoms of COVID-19 in the last 3 weeks? *

Patients will be coming in for treatments at their own risk. RINNOVO will follow all the CDC & OSHA guidelines to insure the safety of their staff and patients. We will not be responsible for any illness associated with your appointment and treatment. Patients responding "yes" to any questions will be refused service by order of the Rhode Island Health Department.

Signature *

Clear

Date: *

Date