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COVID-19 Form

I, (further addressed as ‘the client’), acknowledge that my treatment will be done during a pandemic and that while CAROLINA PINTOS THERAPY, PLLC, and its team, employees, and/or associates comply with the State Health Department and the Center for Disease Control and Prevention Infection Control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees that you will not be infected.

I, the client, certify that I have read the entire informed consent and I agree to all its provisions.

Client Information

Name:
Tested positive for COVID in the last 14 days:
Has COVID-19 Symptoms:
Traveled outside the USA in the past 14 days:

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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September 4, 2021 4:09 am CST

COVID-19 Form Uploaded by Carolina Miranda Pintos - [email protected] IP 76.30.41.67