Coronavirus Intake form for Massage Therapists

HVHC COVID-19 SCREENING QUESTIONS

For the safety of our clients and staff, please complete this form in the 24 hours prior to your visit with Harbor Veterinary House Calls. Be sure that the information you provide is accurate and complete.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number

Please answer the following questions:

Yes

Has anyone in your household tested positive for COVID-19 in the last 7 days?

Does anyone in your household have a high temperature or fever?

Does anyone in your household have a new or continuous cough?

Is anyone in your household experiencing loss or change in sense of taste or smell?

Does anyone in your household have symptoms of COVD-19?

Has anyone in your household been in contact with anyone in the last 14 days who is experiencing COVID-19 symptoms?

Have you or anyone in your household traveled outside of MA in the last 14 days

If you have answered yes to any of the above questions please contact Harbor Veterinary House Calls to reschedule your appointment.
Email: Harborvets@gmail.com
Phone: 617-336-3232
Text: 339-221-0678
REQUIREMENTS FOR YOUR VISIT:

Masks are required to be worn by all participanting in the visit. (Except the dogs and cats!!)

For Cat Appointments: Please have your cat in a carrier or in a small room with no hiding places. Please have a table or countertop that has been cleaned and sanitized that we can use for the exam.

For Dog Appointments: Weather permitting, we will see all dog appointments on a front porch or deck. In the event of inclement, we will move indoors. Please have an area cleaned and sanitized for our use.
Signature

Clear
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

HVHC COVID-19 SCREENING QUESTIONS