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YOUR CART
Entry Screening
Completed by therapist in person prior to client entry to facility.
*
Indicates required field
Name
*
First
Last
Who is checking in?
*
Client
Therapist
Temperature
*
In the last 14 days, have you or anyone you have been in close contact with been diagnosed with COVID-19, has corona-virus type symptoms or is waiting for COVID-19 test results?
*
Yes
No
Have you now, or have you recently had any respiratory or flu like symptoms?
*
Yes
No
If YES to either question, do not allow entry.
*
Allowed entry.
Denied entry.
Notes / Actions taken
*
Length of stay
*
30 - 45 minutes
60 - 75 minutes
90 - 105 minutes
2 hours
7:30am - 2:00pm work
2:00pm - 9:30pm work
7:30am - 9:30pm work
Other - specify below
Other
*
Submit
