COVID-19 Questionnaire and Informed Consent Child's Name * First Name Last Name Within the last 14 days have you , your child, or anyone with whom you've been in contact with been within 6 feet of anyone known or suspected to have COVID-19? Yes No Within the last 14 days have you , your child, or anyone with whom you've been in contact with been with anyone known or suspected to have any illness or disease? Yes No Within the last 3 days, have you, your child, or anyone with whom you have been in contact had fever? Yes No Within the last 3 days, have you, your child, or anyone with whom you have been in contact had a cough, shortness of breath, or trouble breathing? Yes No Within the last 3 days, have you, your child, or anyone with whom you have been in contact had any muscle pain? Yes No Within the last 3 days, have you, your child, or anyone with whom you have been in contact had loss of smell or taste? Yes No Within the last 3 days, have you, your child, or anyone with whom you have been in contact had pain, pressure, or tightness in the chest? Yes No Within the last 3 days, have you, your child, or anyone with whom you have been in contact had nausea, upset stomach, vomiting, or diarrhea? Yes No Do you understand the risk of exposure to COVID-19 no matter how many precautions are taken? Yes No Do you agree for you or your child/ward to have an on-site therapy visit at our facility with all of this in mind? Yes No I understand I can elect to postpone on-site therapy of me or my child/ward. By allowing or participating in on-site therapy, I hereby release and agree to hold Laskin Therapy Group, P.A., or anyone associated with it harmless from, and waive on behalf of myself, my heirs, and any personal representatives, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself, my family member(s), and/or property that may be caused by any act, or failure to act of the group, or that may otherwise arise in any way in connection with any services received from the group, particularly with respect to the COVID-19 pandemic. I understand that this release discharges the group from any liability or claim that I, my heirs, or any personal representatives may have against Laskin Therapy Group, P.A. with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from the group. This liability waiver and release extends to Laskin Therapy Group together with all owners, therapists, and employees Yes No With these things in mind, I consent for me and/or my child/ward, named above, to enter and participate in on-site therapy with Laskin Therapy Group, P.A. Date MM DD YYYY Thank you!
