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Search for:
Home
About
Locations
Our Philosophy
FAQ
What We Offer
Therapy and Counseling
Life and Career Coaching
Fitness Coaching
Nutrition and Wellness Coaching
Yoga, Meditation, and Mindfulness
Groups
Virtual Therapy and Telehealth
Wellness Professionals
Revive Online
Blog
Newsletter
Shop
FREE Consultation
Home
About
Locations
Our Philosophy
FAQ
What We Offer
Therapy and Counseling
Life and Career Coaching
Fitness Coaching
Nutrition and Wellness Coaching
Yoga, Meditation, and Mindfulness
Groups
Virtual Therapy and Telehealth
Wellness Professionals
Revive Online
Blog
Newsletter
Shop
FREE Consultation
Staff Health Screening Form
Chris Obara
2020-08-04T18:28:16+00:00
HEALTH SCREENING FORM
Please complete the below form prior to performing in-person sessions at any of the Revive offices.
Have you or anyone in your household tested positive for COVID-19?
*
Select Answer
NO
YES
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
*
Select Answer
NO
YES
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?
*
Select Answer
NO
YES
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?
*
Select Answer
NO
YES
Are you or anyone in your household a health care provider or emergency responder?
*
Select Answer
NO
YES
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?
*
Select Answer
NO
YES
Have you or anyone in your household traveled out of state in the past 21 days?
*
Select Answer
NO
YES
STAFF PROCEDURES
After completing a treatment session you agree to clean with disinfectant wipes all doorknobs, chairs, and tables in any room or space used during the session.
*
Select Answer
NO
YES
After completing a treatment session you agree to clean with appropriate disinfectant any utensils, cups, and similar items used by yourself or a client.
*
Select Answer
NO
YES
While in the office you agree to follow the mandatory state health & safety requirements, including wearing a face mask?
*
Select Answer
NO
YES
Additional Comments
Staff Name
*
Date
*
Signature
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