Mayan Moon Healing COVID-19 Screening

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This is required prior to your appointment.

Email *

First and Last Name *

Phone Number *

Have you experienced any of the following symptoms within the past 2-14 days? *

Cough

Shortness of breath or difficulty breathing

Fever

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell

None of the above

Required

Have you ever tested positive for COVID-19? *

Yes

Within the last two weeks, have you been in close contact with anyone that was infected, suspected or diagnosed with COVID-19? *

Yes

Have you traveled to another city or country within the last 2 weeks? *

Yes

I agree to notify Mayan Moon Healing immediately at (847) 868-0528 of any changes to the above prior to my appointment. *

Yes

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