Halo Wellness Center Covid-19 screening

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Please complete this form within 24 hours of your scheduled appointment. Failure to complete this form may result in the rescheduling of your appointment. If you answer yes to any of the following please call us to reschedule your appointment. You will not be charged a cancellation fee. If you have any questions please call 856-574-4433. Thank you for understanding!

Have you had any of the following symptoms in the past 72 hours? *

Coughing

Fever or Chills

Shortness of Breath

Difficulty Breathing

Fatigue

Muscle or Body Aches

Headache

Recently loss of Taste or Smell

Sore Throat

Congestion or Runny Nose

Nausea or Vomiting

None of the above

Required

Have you been exposed to anyone that was diagnosed or presumed positive with Covid-19 in the past 14 days? *

Yes

Maybe

By typing my name below I understand that close contact with people increases the risk of infection from COVID-19. By electronically signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage, facial or any alternative treatments at Halo Wellness Center. I release all legal rights and responsibility to legally act against Halo Wellness Corporation (dba Halo Wellness Center) and their private contractors and I accept all responsibility in utilizing any alternative treatments, massage and bodywork at Halo Wellness Center. Please type your full name below. *

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