Would you like a therapeutic or relaxation massage?*

therapeutic
relaxation

Have you had any car accidents, surgeries, trauma or injuries since your last visit?*

Yes
No

For females, are you pregnant?

Yes
No

How many weeks?*

Have you had a recent cancer or cardiac diagnosis?*

Yes
No

Are you currently undergoing chemotherapy?*

Yes
No

Do you have any skin allergies, rashes, or open wounds?*

Yes
No

Would you like to add an Aromatherapy upgrade for $10?

Yes
No

Which essential oil?

Bergamot (Uplifting & Rejuvenating)
Lavender (Calming & Clarifying)
Peppermint (Stimulating & Decongesting)

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?*

Are you currently awaiting Covid-19 test results?*

Yes
No

PLEASE NOTE:

For the safety of everyone in this office, we ask that you please discontinue this check-in process and refrain from entering the office until you receive a negative test result.

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.*

* By ticking the box above and entering your initials below, you verify your identity and that you agree to the noted disclaimer.

I would like to continue maintenance massages (weekly or monthly) Tell me about the rub club!

Select the first letter of your FIRST Name

1st*

Select the first two letters of your LAST Name

1st*

2nd*