Covid Screening — Earthworks Studio

Name

First Name

Last Name

Phone

(###)

###

####

Have you had a fever in the last 24 hours of 100°F or above?

Yes

Have you traveled out of state in the past 14 days?

Yes

If you have traveled, where?

Have you or anyone in your household been diagnosed with COVID19 within the last 30 days?

Yes

Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19?

Yes

I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to proceed with providing care.

Please initial to consent

I understand that in the event that a client or therapist of this business, or family member of this household tests positive for COVID-19 within a time period that places me at risk of exposure, my name and contact information will be shared with the State Department of Health for their follow-up. In the event that I develop symptoms of illness within two weeks of my appointment, I will contact this business immediately.

Please initial to consent

I knowingly and willingly consent to the treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I confirm all of my questions were answered to my satisfaction.

Sign your name as a digital signature

Today's date

YYYY

Covid 19 Safety Screening

Services are offered in Westport, CT and around the world.