Patient Protocol Agreement
This agreement is to attest to the fact that i have been screened clear to treat and will follow the agreed upon protocol to maintain my own safety and that of the practitioner. ______
*i will use my restroom at home before the appointment to minimize my need to utilize one publicly or at the clinic.
*i will be on time, and not early nor late, as treatments have been staggered to minimize or avoid patient interaction in reception.
*i will attend therapy alone, unless a caretaker is required. _______
- I will wait in the car & a staff member will call me to do a “real time” screening over the phone before my entry is permitted.
- I understand that i must enter the clinic with a mask, if i do not have a mask, a surgical mask can be purchased for $2.
- I will only bring a minimum amount of stuff into the clinic (phone, wallet, keys) to decrease surface contacts
- I will bring my own water ( clinic does not provide currently)
- I understand the clinic restroom is only available with urgent situations and with permission, to maintain hygiene. ______
- I will sanitize my hands, if possible, to the mid forearm utilizing the sanitizer provided. if there is an allergy I will ask to use the counter sink
- My Therapist will take me directly to the treatment room.
Treatment Room -
- I will place my personal items on the black shelf or in one location to ensure thorough sanitation.
- Therapist will sanitize hands, and where gloves where possible before treatment.
(Patients: Please inform us of any chemical sensitivity before entry.)
Treatment Room -
-Therapist will sanitize the room as I gather my items.
- I will proceed to checkout, maintaining the distance that the space provides.
- I understand that No paper receipts will be provided (cc receipts will be placed in my file), official receipts will be emailed. Tap payments encouraged (no cash is preferred).
- I understand that Invoices will be sent to you by our admin staff (working at a distance) in 24-48 hours.
- As I leave, any surfaces that may have been touched will be sanitized in preparation for the next patient.
Please note: appointment times may be changed to accommodate social distancing rules.
If you’re experiencing any symptoms, please call and we will reschedule your appointment.
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