Massage Screening

Health Screening

At DeYoung Chiropractic, the health and safety or our staff and patients is top priority. Please complete this questionnaire prior to your scheduled appointment. Temperature checks will be performed prior to your appointment.
Name *

First Name Last Name
Phone Number *
Date and Time of scheduled appointment: *

Month Day Year
Date Hour Minutes AM/PM Option
Have you been in within the last 6 months?

Yes No
Billing Address

Street Address

Street Address Line 2

City State

Zip Code
Please indicate any symptoms that are new or atypical that you are experiencing:

No symptoms; feeling healthy! Cough Shortness of breath Difficulty breathing Loss of taste or smell Fever of >100.4 or feeling feverish within last 72 hours Chills Muscle aches Sore Throat Diarrhea, vomiting, abdominal pain Congestion or runny nose Headache Fatigue
To the best of your knowledge, have you been in close proximity (less than 6 feet) for more than 15 minutes to someone with COVID?

Yes No
When?
Additional notes:
Would you like to pay via credit card now for your appointment?

Yes No
After clicking submit, you'll be redirected to our secure processing page. Please enter your LAST NAME for "invoice number" when prompted.

Our pricing for massages is as follows:

$30 ....... 30 minute session

$60 ....... 60 minute session

$140 ..... (3) 60 minute session
Should be Empty:

Health Screening