Effective June 1, 2020

Please fill out & submit this form the morning of EACH appointment.

Respiratory intake form for massage

For all of our safety, please fill this out within 24 hours of your massage - preferably the morning of your massage (for each massage until further notice). Be sure that the information you give is honest, accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.

I agree to the following

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

Informed Consent for Prolonged Exposure

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 Jessica St. John, LMT.