Return to Therapy Following Illness Certification Form

Your Name - First and Last (required)

Child Name - First and Last (required)

Child Code (required)

Your Email (required)

Please put a check next to each statement indicating agreement (required)

1) It has been at least 3-days (72 hours) since my child has had a fever (100.4° F or higher) without the use of fever-reducing or other symptom-altering medicines (e.g., cough suppressants)
Yes, this is correct.

2) My child has not exhibited respiratory symptoms related to COVID-19 (coughing or shortness of breath) in the past 72 hours without the use of symptom-altering medicines (e.g., cough suppressants)
Yes, this is correct.

3) My child has not exhibited any other symptoms (e.g., loss of taste or smell, gastrointestinal problems, such as nausea, diarrhea, and vomiting) in the past 72 hours without the use of symptom-altering medicines
Yes, this is correct.

4) At least 7 days have passed since my child's COVID-19 symptoms first appeared.
Date symptoms first appeared:
Yes, this is correct.

5) My child has not been in close contact with anyone who has exhibited any COVID-19 symptoms or tested positive for COVID-19 in the past 7 days. *Close contact means living in the same household or being within six feet of a person for 15-minutes
Yes, this is correct.

6) Date to return to therapy:

Please attach Doctor's note:

Additional Information:

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