First Name*

Last Name*

Mobile number*

Email address*

Address*

Apartment, suite or unit number

City*

Preferred phone number:*

How did you hear about me? (referral, Facebook, etc.)*

Have you had a massage/bodywork before?*

Types of massage/bodywork received:*

Preferred types of massage:*

Reasons for seeking massage? (relaxation, injury, etc.)*

Possible complications/medications:*

Have you had a fever in the last 24 hours of 100°F or above?*

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath*

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?*

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*

Do you have special needs I should prepare for:*

Additional Notes