Blissful Healing Wellness

"How old you are is your business...

How 'good' you feel is really my business" Nadia

Soon, the idea of missing an appointment is simply unthinkable!

Respiratory intake form for massage

For all of our safety, please fill this out 24 hours prior to each massage (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Name *

First Name Last Name
Email *
[email protected]
Phone Number *

Area Code Phone Number

In the past 14 days, I have experienced...

Yes

Fever 101°F +

Unexplained body aches or pain

Coughing

Sore throat

Shortness of breath

Chills with or without body aches

Recent loss of sense of smell or taste

Unexplained sores on soles of feet

Unusual fatigue

Non-allergy related runny nose

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Respiratory intake form for massage