Precautionary Coronavirus Liability Release Form - Client

Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices.
Please complete the following and sign below.
    If YES then: Return home and contact public health. You may be required to self-isolate.
  • Symptoms of COVID-19 include:

    • Fever • Fatigue • Dry cough • Difficulty breathing • Chills • Nausea or vomiting • Diarrhea • Confusion
  • Date Format: MM slash DD slash YYYY