I want to ensure the safety and health of you and me! (well how about everyone!) Please submit this form within the 24 hours prior to your appointment time.

First Name

Last Name

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

The following questions are specific to the new aspect of COVID-19 involving blood coagulation:

Can you exercise to get your heart rate and respiratory rate up with out any problem?

Have you had a new onset of muscle aches and pains since the emergence of the virus?

Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?

I declare that the info I’ve provided is accurate & complete

I understand that COVID-19 has been declared a world pandemic by the World Health Organization (WHO)

I hearby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment

Initials

Date

Thanks for submitting!