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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
In the last 3 days, have you or anyone you have been in close contact with, not felt well: headaches, tiredness, cough, flu like symptoms?
*
Yes. You must obtain a negative covid test result or complete a 14 day symptom free quarantine to enter office. -- Deny entry.
No
In the last 14 days, do you or anyone you have been in close contact with suspect you or they may have covid, been diagnosed with covid or is waiting for a covid test result?
*
Yes and I or they have not obtained a negative covid test result. -- Deny entry.
Yes and I or they have obtained a negative covid test result. -- Allow entry.
No
In the last 14 days, have you participated in any socializing, indoors or outdoors, that included persons not living in your home?
*
Yes and I have not obtained a negative covid test result or completed a 14 day symptom free quarantine. -- Deny entry.
Yes and I have obtained a negative covid test result or completed a 14 day symptom free quarantine. -- Allow entry.
No
If YES to any prior question without a negative covid test result or completion of quarantine, do not allow entry or provide reasoning for allowing entry.
*
Denied entry.
All is well so far, continuing pre-entry screening.
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
Temperature
*
Submit
