COVID-19 Questionnaire and Health Screening Form
Prior to your appointment
Please complete this form in order to be able to be seen by one of our qualified employees.
Do you or anyone living in your household currently have any of the following symptoms:
Fever (temperature over 99.5)
Cough/ shortness of breath
Loss of taste/ smell
Is anyone in your household currently under quarantine for a covid 19 related exposure or diagnosis?
DISCLAIMER TO COVID QUESTIONNAIRE: I understand that by attending therapy sessions I am responsible for taking precautions laid out by the CDC to reduce my risk and the risk of others. This includes the risk of spreading illness and I understand there is some level of risks involved in my family leaving our home to attend therapy.
If my child has 2 or more symptoms I will call the office by phone to cancel of reschedule appointment. (Battle Creek: 269-223-7786 or Caledonia: 269-536-2211)
I understand that Functional Kids is taking precautions and safety measures to the best of their ability to prevent the spread of illness and will do my part, if I am medically able, to wear face coverings in the facility.
I assume financial responsibility to pay the cancellation and/or no-show fee if I do not call by noon the business day before my appointment.
COVID Health Screener