Have you ever had a facial?* Yes No When? Why do you want a facial?* to improve my skin to relax Do you have a daily skin protocol?* Yes No Are you interested in learning how to take better care of your skin?* Yes No Are you interested in regular skin maintenance? Yes No Would you like us to tell you about our discounted facial packages?* Yes No In the last week, have you had a fever, a dry or painful throat, headache with sore throat, diarrhea, body aches or cough OR in the last 14 days have you been asked to self-isolate or quarantine by a doctor or had close contact or cared for someone diagnosed with COVID-19?* Yes No When?* Please read the disclaimer below and check the box to confirm* I understand that COVID-19 is highly contagious and still present in the community where I am seeking massage therapy. I understand that COVID-19 is passed through close contact with others and that people without symptoms may be infectious. I understand that Dr. Mel Youngs, D.C., P.A. has taken every precaution to ensure my health and safety, but that risk of infection is still possible. Select the first letter of your FIRST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZSelect the first two letters of your LAST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ2nd*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ