wellnesscheckform

Name *

Email *

Phone *

Within the last 14 days, have you been diagnosed with COVID-19 or had a test confirming you had the virus? *

Yes No

Do you live in the same household, or have you had close contact (been within 6 feet for over 10 minutes) with someone who has been in isolation for COVID-1 or has had a test confirming they have the virus in the past 14 days? *

Yes No

Have you had any one or more of these symptoms today or within the past 24 hours, new or unexplained by another reason?

• Fever (of at least 100.4F(38C)) or chills
• Coughs
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

Yes No

OH NO! WE'RE SORRY TO HEAR YOU ARE NOT FEELING WELL! YOU ARE UNABLE TO RECEIVE MASSAGE SERVICES TODAY.

PLEASE RESCHEDULE YOUR MASSAGE SESSION ONLINE OR WITH THE 87798RELAX REPRESENTATIVE FOR A LATER DATE TO ALLOW YOU TIME TO CONTACT YOUR HEALTH CARE PROVIDER AND BE SYMPTOMATIC FREE.

CONTINUE TO FOLLOW THE FEDERAL AND LOCAL HEALTH GUIDELINES. STAY SAFE WHILE LIVING STRESS-FREE. THANKS FOR YOUR COMMITMENT TO KEEPING OUR COMMUNITY HEALTHY AND SAFE.

Please confirm the information you've provided is correct, complete, and accurate. *

Yes, I confim Not Now