COVID-19 SAFETY PRECAUTION FORM

The following is required to complete prior to your in-person session. Please read the following survey and then respond using the form field below.

Thank you for choosing Peach & Crane, PLLC. The safety of our clients and staff and the communities we serve is our overriding priority. As the COVID-19 outbreak continues to evolve, we will continue to closely monitor developments and may periodically update our policies, procedures, and protocols. To help mitigate the spread and effects of COVID-19, and in order to reduce the potential risk of exposure to clients and staff, we are requiring that each guest complete the following health questionnaire prior to receiving a service.

Please answer NO or YES to the following questions:

  1. In the past 14 days, have you traveled outside of your hometown to any foreign country or area within the US with a CDC Level 3 travel notice or similar State notice?

  2. In the past 14 days, have you been in close contact with someone (family, friend or coworker) who returned from a foreign country with a CDC Level 3 travel notice?

  3. In the past 14 days, have you been in close contact (within 6 feet) of a person who has tested positive for COVID-19?

  4. In the past 14 days, have you personally tested positive for or been infected with COVID-19?

  5. Do you have or have you had in the past 14 days any of the following symptoms: Respiratory illness, fever, cough, headache, sore throat, runny nose, breathing difficulties, loss of sense of smell, unusual fatigue, body aches, or loss of taste?​

Please answer AGREE or DISAGREE to the following statements:

  1. I acknowledge and understand there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including the office building where my appointment will be held. By entering the premises and/or receiving services, I agree to fully assume these risks and release Kirem Marnett, LAC and Peach & Crane PLLC from any and all liability. As a precondition of receiving services, I have confirmed that my answers to this questionnaire are complete, true and accurate. I therefore consent to service rendered by this location on these terms and conditions.

  2. I understand that if I answered YES to any question above, it will be evaluated by Kirem Marnett, LAC and that rescheduling of my appointment may be required.

  3. Upon entering the office, I consent to having my temperature checked via touch thermometer. If temperature is 100 degrees or higher, I understand that I will have to forfeit my appointment and wait to reschedule my services and until I have been fever-free for at least three days. It is highly recommended that each client take their own temperature on the day of their appointment prior to arrival in order to avoid forfeiting appointments.

  4. The courtesy of wearing a mask and having one handy when entering the premises is helpful but is NOT required during your intake and treatment. I understand that for my safety, Kirem Marnett, LAC will wear a mask during the duration of my appointment. If I wish to wear a mask and do not have one, a disposable mask can be provided to me at a cost of $1.00.


Use the fields below to indicate or explain your answers. We thank you for your understanding in keeping you, our staff and community safe!

 
All of my responses were either NO or AGREE
 

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