First Visit

Have you already filled out your new patient paperwork?*

Yes
No

Note: Once you click 'Submit' on this form, you will be redirected to the New Patient Paperwork.

What is the reason you are here today?*

Chiropractic
Massage
Facial

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 agree*

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*