EmailMe Form - Lori Tucker Covid Form

Name *

Date

MM / DD / YYYY

Phone

### - ### - ####

Email

Purpose: Based on the US Center for Disease Control Guidelines, service providers, daily, are encouraged to screen all clients for signs of respiratory illness accompanied by fever.

Instructions: All clients entering Lori Tucker Agency's building must be asked the following questions below. We will maintain this record for 14 days from completion of this form and have this form available upon request from the Public Health Department.

Do you have a new or worsening cough? *

Yes

No

Do you have a new or worsening shortness of breath? *

Yes

No

Have you had a (temperature 100.4*F or greater within the last 14 days) *

Yes

No

Are you feeling feverish? *

Yes

No

Are you having chills? *

Yes

No

Have you been in a facility or home with confirmed COVID-19 by lab test within the last 14 days? *

Yes

No

Have you been with persons with confirmed COVID-19 by lab test within the last 14 days? *

Yes

No

If you answered NO to all questions you will be allowed entry to building.
If you answered YES to any, please call and cancel your appointment immediately.

Please be aware of the following protocols:
• Masks are required
• Surfaces are wiped and a protective barrier is in place
• Sorry I won't be able to shake hands of give hugs during our appointment

By clicking submit, I am acknowledging the potential risk to contract the COVID-19 disease during services provided today and voluntarily agreed to accept services. You further agree and hereby release Lori Tucker Agency and its employees from any and all liability associated with your potential risk to contract NOVEL CORONAVIRUS (COVID-19).