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WELCOME...

WE ARE EXCITED TO BE IN SERVICE

Health & Wellness Questionnaire

Name (First, Last)

Phone

Email

Please read and confirm the statement below by clickng "Submit". I do not A) have a fever now or have in the past 14-21 days, B) have not come in contact with any confirmed COVID-19 positive patients in the last 14 days, C) have a cough, D) am not experiencing shortness of breath or difficulty breathing.

A) I agree to the safety terms & conditions. B) I confirm I do not have any of the symptoms listed above.

Althought exposure is unlikely, by clicking on the box, I accept the risk and consent to treatment.

Thanks for submitting!

Please contact us for free consultations. Thank you!

© 2019 by OC Therapists L.L.C.