In the past 20 days, have you tested positive for Covid-19 or potentially come in contact with someone who has? *

YES

NO

In the past 20 days, have you experienced any of the following symptoms: coughing, fever, nausea, vomiting, sore throat, sudden loss of smell or taste, severe fatigue, or muscle aches unrelated to an injury? *

YES

NO

In the past 20 days, have you traveled internationally or to a United States community that is experiencing sustained community spread of COVID-19? *

YES

NO

Name *

First Name

Last Name

Emergency Contact

First Name

Last Name

Terms of Service *

I acknowledge that I have read, understand, and agree to be bound by the Little Star Therapeutic Massage Terms of Service (the "Terms of Service"), including without limitation the waiver and release of liability therein which among other things releases Little Star Therapeutic Massage from any liability related to COVID-19. I further acknowledge that the Terms of Service may change from time to time and that it is my responsibility to review such terms prior to booking new services with Little Star Therapeutic Massage, LLC (the "Company") and to notify the Company in the event I longer agree to be bound by the Terms of Service.

YES

NO

Privacy Policy *

I acknowledge that I have read and understand the terms of the Little Star Therapeutic Massage, LLC Privacy Policy located at http://www.littlestarmassage.com/privacy-policy (the "Privacy Policy"). I further acknowledge that the terms of the Privacy Policy may change from time to time and that it is my responsibility to review such terms prior to booking new services with Little Star Therapeutic Massage (the "Company"), and to notify the Company in the event I longer agree to the terms of the Privacy Policy.

YES

NO