Name
*
First Name
Last Name
Covid 19 screening form
For all of our safety, please fill this out prior to each massage. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Email
*
example@example.com
In the past 10 days, I have experienced...
*
Yes
No
Fever or chills
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose
Diarrhea
Headache
Nausea or vomiting
Phone Number
*
-
Area Code
Phone Number
Signature
*
Submit
Should be Empty: