Infectious Disease Questionaire

Thank you for your continued trust! If you have been exposed to a communicable disease, you may spread the disease to the staff or other patients/parents in the practice. Therefore, prior to each appointment we will be asking the following questions to reduce the chances of transmission:

I understand that if the answer to any of these questions is yes, I will be asked to reschedule, or the appointment may be conducted online to reduce transmission risks. Signature_______________________________________________ Date_________________ As with the transmission of any communicable disease like the cold or flu, you may be exposed to COVID-19, at any time or any place. Be assured I have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite the careful attention to sterilization, disinfection and use of personal barriers, there is still a chance that you could be exposed to an illness in the office, just as you may at other places you travel. “Social distancing” has reduced the transmission, however, due to the nature of this therapy, it is not always possible to maintain a six-foot distance between the therapist and the client/patient.

Signature__________________________________________________ Date________________
Child’s name if applicable_________________________________________________________