Client Forms

Intake Form COVID-19 Addendum

To best protect your health and the health of others, please fill out this form before each massage session. Thank you!

Have you been tested for COVID-19? 

Have you been in a places with a high infection rate within the last two weeks?

Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:

Do you have any new discomfort with exertion or exercise?

To best protect your health and the health of others, please fill out this form before each massage session. Thank you!

Your Signature

156 East Avenue, second floor

Norwalk, CT 06851

info@mysite.com

Tel: 203.984.0407

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© 2016 by Jan Scaglia