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Covid-19 Symptoms Check-In (to be filled 24 to 48 hours prior to your appointment time).

Question Title

* 1.
Within the last 21 days, have you experienced one or more of these symptoms?

Fever or chills?

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Yes

Question Title

* 2. Based upon Governor Cuomo’s Executive Order 205, issued June 25, 2020, the following states and territories meet the criteria for required quarantine.

Have you visited any of these states within the last 14 days?

Alabama

Alaska

Arizona

Arkansas

California

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maryland

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

North Carolina

North Dakota

Oklahoma

Puerto Rico

South Carolina

South Dakota

Tennessee

Texas

Utah

Virginia

Virgin Islands

Wisconsin

Yes

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* 3. Within the last 21 days, have you been in close contact with anyone who has been confirmed or is suspected to have of COVID-19?

Yes

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* 4. Do you agree to arrive at the office at your specific appointment time?

Yes

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* 5. Do you agree to not bring anyone with you to your appointment (unless the client is minor who needs a guardian)?

Yes

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* 6. Do you agree to put on a mask before entering the clinic and keep it on at all time?

Yes

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* 7. Do you agree to undergo temperature check and brief pre-screening before entering the clinic for your appointment?

Yes

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* 8. Anything else you would like to share in relation to Covid-19?

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* 9. If you answered "yes" to any questions or have any of the signs or symptoms, you may need to reschedule your appointment. Delia will contact you for further information and guidance.
If you have answered "no" to all questions and have no symptoms for the past 21 days, you may proceed with your appointment without further guidance.

Name *

City/Town *

State/Province

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

Question Title

* 1. Within the last 21 days, have you experienced one or more of these symptoms? Fever or chills? Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea

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Question Title

* 3. Within the last 21 days, have you been in close contact with anyone who has been confirmed or is suspected to have of COVID-19?

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* 4. Do you agree to arrive at the office at your specific appointment time?

Question Title

* 5. Do you agree to not bring anyone with you to your appointment (unless the client is minor who needs a guardian)?

Question Title

* 6. Do you agree to put on a mask before entering the clinic and keep it on at all time?

Question Title

* 7. Do you agree to undergo temperature check and brief pre-screening before entering the clinic for your appointment?

Question Title

* 8. Anything else you would like to share in relation to Covid-19?

Question Title

* 1.
Within the last 21 days, have you experienced one or more of these symptoms?

Fever or chills?

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea