Pre Appointment Health Questionnaire - Bevill and Associates Behavioral Health

COVID -19 Pre Appointment Questionnaire and Attestment

The safety of our clients, staff, families and visitors remain Bevill and Associates Behavioral Health overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads. Only clients with scheduled appointments are permitted into our office. We ask that client 14 yrs of and older enter the office and one under the age of 14 years of age will be allowed to be accompanied by one adult family member. To prevent the spread of COVID-19 and reduce the potential risk of exposure to other clients and our staff we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in the office.

Name *

First

Last

Clients Name

Date of Birth *

Clients Date of Birth

Appointment Date and Time

Date

Time

Clients appointment date and time

Self-Declaration

Have you traveled outside of the State of Alabama in the last 14 days? *

Yes
No

Have you had contact with anyone with confirmed COVID-19 in the last 14 days? *

Yes
No

Have you had any of these symptoms in the 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing) *

Yes
No

Have you had a fever greater than 100 in the last 24 hours? *

Yes
No

I attest that my response to all questions are accurate and truthful. By signing this questionnaire I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by entering the offices of Bevill and Associates Behavioral Health that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Bevill and Associates Behavioral Health may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Bevill and Associates Behavioral Health employees, clients and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my counseling appointment (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless the Bevill and Associates Behavioral Health , its employees, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind.

Name *

First

Last

By typing your name you are providing electronic signature.

Name