COVID-19 WELLNESS FORM - MOBILITYSALON.COM - MobilitySalon.comMobilitySalon.com

Name*

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Email Address*

Phone*

Appointment Date*

You should be submitting this form within 24 hours prior to your appointment.

Appointment Time*

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You should be submitting this form within 24 hours prior to your appointment.

Do you have a cough?*

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No

Do you have a fever now, or have you had a fever in the past 14 days?*

Yes
No

Have you come in contact with any confirmed COVID-19 positive patients within the last 14 days?*

Yes
No

Are you experiencing unusual shortness of breath or difficulty breathing?*

(This is not referring to normal conditions such as asthma.)

Yes
No

Are you experiencing other flu-like symptoms?*

Yes
No

Have you experienced recent loss of taste or smell?*

Yes
No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

Yes
No

Have you traveled into New York State from one of the following States within the past 14 days? If yes, please select the State.*

Do you have a friend or relative staying or living with you who has traveled into New York State from one of the following States within the past 14 days? If yes, please select the State.*

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COVID-19 WELLNESS FORM – MOBILITYSALON.COM

COVID-19 WELLNESS FORM - MobilitySalon.com