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?* 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 Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZSelect the first two letters of your LAST Name1st*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ2nd*SelectABCDEFGHIJKLMNOPQRSTUVWXYZ
