Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Date of Service *

MM

DD

YYYY

Fever of 100.4 ºF or higher *

Yes

No

Shortness of breath or trouble breathing *

Yes

No

Unexplained coughing *

Yes

No

Runny nose (not from seasonal allergies) *

Yes

No

Sore throat *

Yes

No

Recent loss of smell or taste *

Yes

No

Unexplained body aches or pain *

Yes

No

Chills or shaking with or without body aches *

Yes

No

Unexplained sores on soles of feet *

Yes

No

Unexplained body rashes *

Yes

No

Unusual fatigue *

Yes

No

Unexplained diarrhea or gastrointestinal distress *

Yes

No

Checkbox *

I agree to the following:

I affirm that I, as well as those in my household, have not been diagnosed with COVID-19 within the last 30 days.

I affirm that I, as well as those in my household, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from My Favorite Feet Massage.