Wellness Program Service Check-in Form
Please complete this form to check in for your wellness program session. Your responses help us provide you with safe and personalized service.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Check-in
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Which wellness service are you checking in for?
*
Please Select
Yoga Class
Massage Therapy
Nutrition Consultation
Meditation Session
Fitness Training
Other
Have you experienced any of the following symptoms in the past 48 hours? (Select all that apply)
*
Fever or chills
Cough or sore throat
Shortness of breath
Muscle aches
None of the above
Other
In the last 14 days, have you been in close contact with anyone diagnosed with a contagious illness?
*
Yes
No
Not Sure
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any health concerns or conditions we should be aware of before your session?
Additional Comments or Requests
Check In
Should be Empty: