Please be honest when filling out this form. The information you provide is confidential and will not be shared with outside parties. Due to the outbreak of COVID-19, we are taking extra precautions with the intake of each client, healthy history review, as well as increased sanitation and disinfecting practices. Please complete the following and sign below.

Symptoms of COVID-19 include:
-Difficulty Breathing
-Dry Cough
-Sore Throat
-Skin Rashes
-Sudden loss of taste or smell