TNTMS COVID-19 Patient Questionnaire and Waiver

Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Are you currently experiencing any NEW symptoms listed below that are not due to another health condition? Check all that apply:*

Did you check any of the above symptoms?*

YES: Please call the office to change your appointment to Telemedicine or to reschedule.NO

Have you tested positive for Covid-19 within the last 5 days?*

YES: Please call the office to change your appointment to Telemedicine or to reschedule.NO

Please be aware of our current policies and procedures at True North TMS at Willow Medical for COVID-19 mitigation:

Hand Sanitizer will be available for you at the entry or you may wash your hands with soap and water in our Lobby facilites.
We ask that you wear a mask in ALL public areas of our building.
Your temperature will be taken by your provider upon entry.
Please maintain 6ft distance with other clients to the extent possible.
For your protection and safety, we are taking measures to screen patients at risk or with active symptoms of COVID-19. We have installed UV filters in our Central HVAC system. We have additional HEPA/UV filters through out the building. We have created a socially distanced Lobby area and removed magazines. There will be no beverage/snack service for the time being. We have implemented routine cleaning protocols to ensure that frequently touched areas are sanitized and cleaned. We have made our intake and check-out process as touchless as possible. All of our forms can be filled out online.

By signing this form, I hereby acknowledge that I have read, understand, and agree to follow the facility rules as outlined above. I declare that the information I have given above is correct and valid to my knowledge.

I, also, acknowledge the potential risk to contract the COVID-19 disease during in-person services provided in this facility and I voluntarily agreed to accept this risk. I, also, accept that the facility cannot be held responsible for the transmission of COVID-19.

Signature*

Date*

Date