Pre-Appointment Covid-19 Screening

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KNOSIS Physiotherapy & Wellness
212.906.4440
info@knosiswellness.com

In our effort to keep everyone safe, we ask that you complete and submit this brief Screening Form before you arrive for each appointment.

First and Last Name *

Are you vaccinated? *

Yes, fully vaccinated for Covid-19

Yes, fully vaccinated for Covid-19. I also have a booster

No, I have not been Vaccinated for Covid-19

Have you experienced cold like symptoms or a fever in the past 24 hours?

Yes - If yes, please bring negative COVID-19 test result before your appointment

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Have you been diagnosed with or been exposed to someone diagnosed with COVID-19 in the past 10 days?

Yes - If yes, please call our office before your next appointment.

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For your safety as well as ours, we ask if you develop any symptoms of Covid-19 after or between appointments that you notify our office at 212.906.4440 *

I agree to notify KNOSIS if I develop any symptoms of Covid-19

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