Wellness uprising client intake form

I understand that the coronavirus causes the disease known as COVID-19. I understand the coronavirus has a long incubation period during which the carriers of the virus may not show the symptoms and may still be contagius.

I understand that:

  1. physical distancing of 6’ may not be possible while receiving services

  2. I must wear a face mask while on the premises, including while receiving services

  3. I must make all attempts to cover my mouth and nose in the event of coughing and/or sneezing and then immediately sanitize my hands

  4. I will minimize the touching of common surface/areas

  5. I may not bring children or anyone who does not have an appointment into the office

  6. I understand the Practitioners of Wellness Uprising will do everything possible to minimize the spread of COVID-19, but I will not hold them responsible should I contract COVID-19

I confirm that:

  1. I am not currently positive for COVID-19

  2. I am not waiting for the results of a laboratory test for COVID-19

  3. I have not returned to California from any other state or country, whether by car, air, sea, bus or train in the past 14 days

  4. I have not been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by any medical advisor or government agency

  5. I am not presenting with any of the following symptoms of COVID-19:

    • Fever >100F, 30C, chills or body aches

    • Cough

    • Sore throat

    • Shortness of breath/Difficulty breathing

    • Flu-like symptoms

    • Runny nose

    • Loss of smell or taste

    I will immediately notify Wellness Uprising if I contract the virus within two weeks following my visit.

    By completing and submitting the form below, I verify that this form is truthful and accurate.