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

©2020 Functional Kids Therapy. Proudly created by JPIXEL

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

  • Pinterest
  • Facebook - Black Circle
  • Instagram

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

  • Pinterest
  • Facebook - Black Circle
  • Instagram
FunctionalKids-Logo-MAIN.png
  • Facebook - Black Circle
  • Instagram
  • Pinterest