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Christopher Leeder
Licensed Massage Therapist

Health Waiver Form

Please fill out the following form to provide more information prior to your appointment.

First Name

Last Name

Email

Date of Birth

Have you tested positive for Covid-19 within the last 14 days?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

Have you had surgery or been hospitalized in the last 12 months?

No

Yes

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Integral Massage & Therapeutics // Christopher Leeder LMT

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