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To prevent the spread of COVID-19 and reduce the potential risk of exposure to our team and other clients, we are conducting a simple screening questionnaire. Your participation is important and required to help us take precautionary measures to protect you and everyone in this building. Thank you for your time, considerations, and truthful responses.

You understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. *


  • You agree to reschedule if you cared for someone diagnosed with COVID-19 within the 14 days of appointment. *


  • You confirm that you are not presenting any of the following symptoms: fever, new or worsening chronic cough, sore throat or painful swelling, shortness of breath, or flu-like symptoms. *


  • You confirm to your knowledge that you are not currently positive for COVID-19. *


  • You confirm that you are not currently waiting for laboratory results for COVID-19 testing. *


  • You agree to wear a mask at the time of your appointment. *


  • You agree to follow additional guidelines set forth by me. *


  • By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk I may be exposed to or infected by COVID-19 by my mere presence within this establishment and such exposure or infection may result in personal inju *


  • I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I here *

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