COVID-19 Consent
*NOTE: Must be completed prior to each session. Families and staff are required to agree Pediatric Interactions' COVID-19 protocols. In you answer "Yes" to any of the following questions, in-person services may not be conducted. In-person services will be reinstated per guidelines of the CDC.*
Name of person completing assessment*
Name of person coming into clinic*
Date of assessment*
Does any member of the household come into contact with a confirmed case of COVID-19?*
Yes
No
Has any member of the household come into contact with a confirmed case of COVID-19?*
Yes
No
Has any member of the household shown signs of COVID-19, as outlined by the CDC, such as cough, shortness of breath, runny nose, sneezing, respiratory illness and/or fever within the last 7 days?*
Yes
No
Has any member of the household has a fever of 100.4 or higher?
Yes
No
Has any member of the household travelled internationally within the past 14 days?
Yes
No
Submit
Marketing by
ActiveCampaign