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Olympia Family Acupuncture

Denise Robison EAMP

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Pre-Treatment Appointment Check-in

PRE-TREATMENT APPOINTMENT CHECK-IN
Submit this form when you arrive for your visit.

How was your last treatment?

10 DAY COVID 19 STATUS: * Required

I HAVE NOT TESTED POSITIVE FOR/ OR BEEN EXPOSED TO COVID OR FLU

I HAVE NOT EXPERIENCED SUDDEN FEVER or CHILLS, FATIGUE or ACHING

i HAVE NOT EXPERIENCED ACUTE RESPIRATORY SYMPTOMS -EARS EYES NOSE THROAT

I HAVE NOT BEEN EIXPOSED TO A PERSON WITH THE ABOVE SYMPTOMS

If you have answered yes to any of the above selections

THANK YOU--COME ON IN!!!

Please bring your mask.

CV19 Safety Procedures

Directions to OFA

Olympia Family Acupuncture
2550 South Bay Rd. NE
Olympia, WA 98506 Maps link
360-357-5353
OlympiaFamilyAcupuncture.com

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