Health Screening Form
GYROTONIC® Soho – Movement Beyond
First Name: ____________________________
Last Name: ___________________________
Date of Birth: __________________
Address: ______________________________________
City: _________________________ State: __________________
Zip: __________________
E-Mail: ______________________________________
Phone: _________________________
Health Screening Form
The safety of our clients and instructors are of the utmost importance to us.
Given the recent COVID-19 outbreak, we are requiring all clients to complete this screening form prior to their first visit with us since March 16th, 2020.
Please note that we reserve the rights to reschedule your session if you have answered yes to any question below. Please answer these questions truthfully and accurately, so that we may ensure that you receive your service at the appropriate time and setting. Please note that all of your responses will remain confidential.
Questions
1. Have you or a member of your household had any of the following symptoms in the past 14 days: fever/chills, cough, shortness of breath or difficulty breathing, fatigue, muscle/body sore, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea/vomiting, diarrhea or temperature at or greater than 100 degrees ºF?
YES NO
2. Have you or a member of your household been tested positive for COVID-19 in the past 14 days?
YES NO
3. Have you or a member of your household traveled outside the U.S. in the past 14 days?
YES NO
4. To the best of your knowledge, have you been in close contact to any individual who tested positive for COVID-19 in the past 14 days?
YES NO
Disclosure
I acknowledge the contagious nature of COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I am following all CDC recommended guidelines as much as possible and limiting my exposure to COVID-19. I acknowledge that I must comply with all set procedures and protocols to reduce the spread while attending my session at GYROTONIC® Soho – Movement Beyond, Studio 580 L.L.C.
I further acknowledge that GYROTONIC® Soho – Movement Beyond Studio, 580 L.L.C. cannot guarantee that I will not become infected. I voluntarily seek the services provided by GYROTONIC® Soho – Movement Beyond, Studio 580 L.L.C. and acknowledge my risk to exposure.
I hereby release and agree to waive on behalf of myself all causes of action, claims, demands and damages. I release GYROTONIC® Soho – Movement Beyond, Studio 580 L.L.C. from any responsibility to act, or failure to act, or that may otherwise arise in any way in connection to GYROTONIC® Soho – Movement Beyond, Studio 580 L.L.C.
I understand that this agreement discharges GYROTONIC® Soho – Movement Beyond, Studio 580 L.L.C. from any liability or claim I may have.
This form will be kept minimum period of 28 days and the information will be shared with the state and local health departments upon requests.
I have carefully read the above release and fully understand and agree.
______________________________________________________________________________
Signature Date
GYROTONIC® Soho – Movement Beyond
Studio 580 LLC
580 Broadway Suite 1206, New York, NY 10012
646-613-8086
www.movementbeyond.com