In-Person Visit COVID Exposure Questionnaire
Given the recent COVID-19 outbreaks and its variants, we are asking a few questions in connection with your scheduled appointment. These are designed to help promote your safety, as well as the safety of our staff and other patients. We are asking the same questions to all patients, PRIOR TO EVERY IN-PERSON SESSION, for everyone’s safety. So that we can ensure that you receive care at the appropriate time and setting, please answer these questions truthfully and accurately. All of your responses will remain confidential. We will provide any additional guidance regarding whether any adjustments need to be made to your scheduled appointment as needed.

After you submit these answers, please return to the in-person session information page https://bodytemplept.com/in-person-session-information to pay and obtain directions (including the door code) to the studio.

 Thank you for your understanding. Please Spread Love, Not COVID-19.
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First Name *
Last Name *
Best phone number (preferably mobile/cell for texts) to reach you on the day of our appointment. *
1. Have you had any symptoms in the last 14 days: Fever, chills, body aches, nasal congestion, sore throat, diarrhea or loss of taste and smell? *
If yes, please describe:
2. Have you tested positive for COVID-19 in the past 14 days? *
If yes, please describe:
3. In the last 14 days, have you been in close contact with someone who tested positive for COVID-19? *
If yes, please explain:
4. Have you been completely vaccinated for COVID-19? *
If desired, please add any notes or relevant information  before our upcoming session:
By checking the box below, I understand that due to the nature of the non-essential healthcare service being reserved, if I do not cancel this appointment prior to 24-hours of my reserved start time, I am responsible for the full cost of the service. I will receive an automated 48-hour email reminder from FullSlate, which provides a 24 hour window to cancel without charge.  If, within 24 hours of the start time of my appointment, including the pre-appointment screen, I exhibit any one of the following symptoms [sore throat, cough, congestion or runny nose (even if I think it is just allergies), chills, muscle or body aches for unknown reasons, shortness of breath or difficulty breathing for unknown reasons, fatigue, headache, nausea or vomiting, diarrhea, loss of smell, loss of taste, fever, temperature at or greater than 100 degrees Fahrenheit], I am still responsible for the cost of the full service I am scheduled for. *
Required
Thank you. Our Physical Therapist will review this information prior to your appointment time and will contact you if there are any issues. Please note that our office requires that all patients and visitors follow CDC guidance regarding face coverings to prevent the spread of COVID-19. For that reason, we ask that you please wear a cloth face covering or mask to your appointment. Unless you hear otherwise from us, we look forward to seeing you at your appointment soon!
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