(269) 223-7786

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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

Sore throat

Runny nose

Headache

Loss of taste/ smell

Extreme fatigue

None

Is anyone in your household currently under quarantine for a covid 19 related exposure or diagnosis?

YES

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.

Notice of Privacy Practices

BATTLE CREEK LOCATION

777 Goguac St W. Suite B2
Battle Creek, MI. 49015

Phone: ( 2 6 9 ) 2 2 3 - 7 7 8 6
Fax: ( 2 6 9 ) 9 6 2 - 9 5 6 9

CALEDONIA
LOCATION

9809 Cherry Valley SE Suite D
Caledonia, MI. 49315

Phone: ( 6 1 6 ) 5 3 6 - 2 2 1 1
Fax: ( 2 6 9 ) 9 6 2 - 9 5 6 9

SCHOOLCRAFT
LOCATION

403 North Grand Street
Schoolcraft, MI. 49087

Phone: ( 2 6 9 ) 6 7 9 - 7 3 7 2
Fax: ( 2 6 9 ) 2 2 5 - 0 1 0 5

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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.

BATTLE CREEK LOCATION

CALEDONIA LOCATION

SCHOOLCRAFT LOCATION

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.

CALEDONIA
LOCATION

SCHOOLCRAFT
LOCATION