COVID-19 | cdslp

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Contact us at: 302-674-3350
Dover Office: 541 South Red Haven Lane, Dover DE 19901
Lewes Office: 17605 Nassau Commons Blvd, Suite B, Lewes DE 19958

Serving our community since 2008

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Covid-19 Daily Check in Form

Please complete this form prior to your child's scheduled appointment.

Patient's First Name

Patient's Last Name

Parent Email

Today or in the last 48 hours, have you, or any household members or caregivers had any of the following COVID-19 symptoms?

Fever (100 F or above)

Shortness of breath/difficulty breathing

Lost of smell/taste

No symptoms to report

Are any of the following statements true? Check all that apply.

Your child has been given medicine to lower a fever in the past 48 hours.

You, your child, or household member is awating the results of a COVID-19 test.

You, your child, or household member has traveled outside the U.S. during the past 14 days.

You, your child, or household member has come in contact with anyone who has been diagnosed or had a presumed case of COVID-19 within the past 14 days.

None of the above statements are true.

If your child is displaying non-COVID 19 related symptoms, please describe them below (i.e. allergies, cold, etc).

I declare that the info I’ve provided is accurate & complete. I understand that if my child displays an elevated temperature upon arriving for their session, or displays any symptoms of COVID-19, his/her appointment will be cancelled and rescheduled to teletherapy until they are symptom free for 48 hours without the use of medication, or have received a negative COVID-19 test result.

Initials

Date

Thanks for submitting!

HOME
ABOUT
- OUR PROGRAMS
- Speech Language Milestones
OUR STAFF
FORMS/POLICIES
BLOG
CONTACT US
- EMPLOYMENT
UPLOAD DOCUMENTS
More

Use tab to navigate through the menu items.

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