Respiratory illness intake form
For the health and safety of our community, declaration of illness (or lack thereof!) is required prior to receiving 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.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Check anything you've experienced in the last 14 days
*
Fever 101F +
Unexplained body aches/pains
Coughing
Sore throat
Unexplained sores on soles of feet
Shortness of breath
Non-allergy related runny nose
Chills with or without aches
Unusual fatigue
NONE OF THESE
Signature
Submit
Should be Empty: