Appointment Check-In and Screening

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Please contact your practitioner if you have questions or concerns regarding any of the following questions or reminders. We request that you complete this form within 24 hours of your appointment. If for any reason you feel it is necessary to reschedule your appointment, please contact us as soon as possible.

Per government guidelines, and to increase safety, we are asking all clients and staff to wear a mask in our office. If you wish to bring your own you are welcome to. However, we have cloth masks that have been cleaned and sanitized available for you to use. We will have a station set up outside of our office door with hand sanitizer and sealed masks. Please remember to use the hand sanitizer and ensure you put on your mask prior to coming in.

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

Yes

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

Yes

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

Yes

Have you been diagnosed with COVID-19 in the last 14 days, or had coronavirus-type symptoms? *

Yes

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

Yes

Do you have any specific needs, goals, or concerns you'd like be to know about in preparing for your appointment? (examples: discomfort in a specific area, new medical conditions or medications since your last appointment, etc.) *

If receiving a 90-Minute service, would you like hot stones to be used during your session? *

Yes

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