Covid Self Declaration Form

Covid Self Declaration Form

For the health and safety of our community, declaration of illness is required. Please submit this screening promptly.
Name *

First Name Last Name
Email
example@example.com
**If it has been two weeks since your second Covid Vaccine and you have no Covid symptoms, you can disregard this form. Please inform staff member when you check in.

In the past 2 weeks, have you had a new onset of any of these symptoms? *

Yes

Fever

Cough

Shortness of Breath / Difficulty Breathing

Chills

Sore Throat

Loss of taste or smell

Increasing Muscle Aches - not related to PT condition

In the past 2 weeks: *

Yes

Have you been asked to quarantine?

Have you been exposed to someone who is positive for Covid-19?

Have you been exposed to someone with symptoms/suspected of Covid-19? **

Have you traveled out of state?**

If you answered yes to any of the questions, please do one of the following:

1. Call and reschedule your appointment

2. Call to switch your appointment to telehealth.
By submitting this form I declare all of the answers are true and I am not aware of having any risk factors for Covid-19.
Date *

Month Day Year
Date
Should be Empty: