Facial Check In

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?*

Have you been to our office since we reopened in April?*

Yes
No

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 Name

1st*

Select the first two letters of your LAST Name

1st*

2nd*