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

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: