REQUIRED FOR EACH APPOINTMENT

Please fill out this electronic form prior to your appointment.

If you prefer, you can print and bring this signed form to your appointment instead.

Symptoms of the COVID-19 virus include:

• Fever
• Fatigue
• Dry cough
• Difficulty breathing

Name

First Name

Last Name

Email

I understand the symptoms above and affirm that I, as well as all my household members, do not currently have these symptoms, nor have experienced them within the last 14 days.

I affirm that I, as well as all my household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the last 14 days.

I understand that Jane Sullivan and Pink Moon cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

I agree to each statement above and release Jane Sullivan and Pink Moon from all liability for the unintentional exposure or harm due to COVID-19. My submission of this form acts as a binding signature.

C-19 Intake Form

REQUIRED FOR EACH APPOINTMENT

Symptoms of the COVID-19 virus include: