CTBI Clinic Check-in Screening
CTBI plans to do its part to help keep you safe while your at our facility. We ask that you also be willing to take certain precautions for the safety of everyone. We will be providing KN95 masks should you not have your own ($3.50 additional charge). Cloth masks provide minimal protection, which is why we require KN95s.
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
We will be requiring that clients wear KN95 masks during their treatment and any time in the studio when less than 6 ft away from another individual. We will be providing KN95 masks for those who do not have them. Can you agree to following this guideline?
Yes
No
Have you had a fever in the last 24 hours of 100º or above?
Yes
No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
Yes
No
Other
Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes orlesions?
Yes
No
Other
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Yes
No
Other
Temperature Day (we will use a contactless thermometer)
Submit
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