COVID-19 Screening Form

COVID-19 Screening Form

Please complete the following form 24-HOURS before making an appointment.
Answer all questions.
We will contact you to confirm your appointment.

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  • If you answered NO to all the questions, complete, sign and submit this form, than proceed to book your appointment.

  • If you answered YES to any of the questions, you MUST RESCHEDULE at another time please follow AHS protocols.

  • My signature below confirms that I assume all risks associated with my appointment and treatment.

  • Tap to sign

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Rejuvenation Health Services