Covid Prescreening Form

Prescreening is required for all client visits. In collaboration with best practices, and for the safety of all of us, please answer the following questions:

Client Name

Date

1. Have you been fully vaccinated?

YesNo

2. Do you have a temperature

YesNo

3. Have you been exposed within the last two weeks to anyone who may have had
Covid?

YesNo

4. Are you at all symptomatic with dry cough, fever, unusual fatigue, shortness of
breath; or have at least two of the following: fever, chills, repeated shaking with chills,
new muscle pain or headache, sore throat, new loss of taste or smell?

YesNo

If you answer yes to questions 2-4, please call your practitioner before scheduled appointment as it may need to be rescheduled.

Procedure upon arriving at Crossings

1. Face coverings must be worn within Crossings space.

2. We request your arrival be as close to your appointment as possible. Every effort will be made to escort you into treatment rooms promptly.

3. Social distancing will be required in the space at all times. Seating, if physically necessary, will be 6 feet apart. Arrows will indicate the flow of traffic through the hallways.

Payment Process: For safety we are initiating a more contactless system at front desk
1. Clients will pay before each visit. We request that credit card information be stored in our encrypted scheduling software system so that on subsequent visits charges can be automatically made.

Please type your name to indicate that you have read this document.

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