We kindly request that you complete this form prior to your appointment. This will ensure a faster and more prompt appointment time for you. Thank you for your help.

Please review our policy page and our COVID Policies page for updates.


Of note: we will not be able to see you if you have been exposed to, or have been ill (flue, cold, COVID or variant)  in the last 30 days. 

We will have to reschedule your appointment.

Thank you for your understanding.

Please complete this form for any service your are booking. 

Covid, Flu, Illness - Health Declaration

How are you feeling today?

Thank you for submitting this form.

We will keep it on file, per Oregon Rules and Regulations, for your upcoming appointment.

You may also print this form and bring it with you to your appointment.