BBVJ Client COVID-19 Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

E-Mail*

example@example.com

Have you experienced any symptoms linked to COVID-19?*

YesNo

Have you been in contact with anyone confirmed to have COVID-19 in the last 14 days?*

YesNo

Have you visited any high-risk areas in the last 14 days?*

YesNo

Have you traveled outside of Los Angeles County in the last two weeks?*

YesNo

If yes, where?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from the treatments received. I am aware that it is my responsibility to inform BODY BY VITAL JOULE of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or professionals from liability and assume full responsibility thereof.*

I understand.

Your Signature*

Clear

Date*

Date