Acupuncture: Redwood City | San Carlos | Menlo Park | Integrative Medicine

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COVID-19 Release Form

COVID-19 Protecting Each Other
Our priority is the health and safety of our patients. To reduce the potential risk of exposure to and transmission of Coronavirus (COVID-19), we are requiring completion of a simple screening questionnaire for all visitors to our office.
We also ask that you adhere to all COVID-19 related preventative measures in effect at our office. Thank you for your support in these measures to protect yourself and the community at large.

Face covering is required during the appointment time.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

1. Have you - or has anyone with whom you have had close contact in the last 14 days (roughly 6 feet or living in the same Household) - been diagnosed with COVID-19?Choose One *

Yes No

2. Are you - or is anyone with whom you have had a close contact in the last 14 days(roughly 6 feet or living in the same household) - awaiting the results of COVID-19 test? *

Yes No

3. Has a public health official or healthcare provider told you - or anyone with whom you have had close contact in the last 14 days (roughly 6 feet of living in the same household) - that you/they are suspected of having COVID-19 or should self-quarantine due to potential COVID-19 exposure(s)? *

Yes No

4. Do you - or does anyone with whom you have had close contact in the last 14 days (roughly 6 feet or living in the same household) - have COVID-19 or flu-like symptoms such as fever, cough, sore throat, or shortness of breath? *

Yes No

5. Within the last 14 days, have you - or has anyone with whom you have had close contact (roughly 6 feet or living in the same household) - traveled to or from an area with known COVID-19 spread (eg. Europe, Asia, New York City, Detroit, New Orleans, etc.)? *

Yes No

Certification
I hereby confirm that my responses are true and correct. By Completing and signing this form, I confirm to Tangible Acupuncture & Integrative Medicine that my presence at my address will not knowingly put anyone at risk of exposure to COVID-19.
I further recognize that the World Health Organization has declared a COVID-19 pandemic and that a national emergency has been declared related to the pandemic. I recognize, acknowledge, and accept the health risks of entering Tangible Acupuncture & Integrative Medicine offices.

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