Nail Care Consultation Form

Nail Care Consultation Form

Manicure/Pedicure/Barefoot Services
Name

First NameLast Name
Email
example@example.com
Birth Date

MonthDayYear
Best Contact #

Area CodePhone Number
Health Information:
Do you have any known allergies?: (latex, aspirin, shellfish, iodine, food, etc...)
Are you currently being treated by a physician for any conditions?
Please list any medications/vitamins that you are taking:
Do you have, or have you ever been diagnosed with a nail infection on either your fingers or your toes?
If answered yes above, please explain
Contraindications that require Medical Permission- Client must give informed consent in writing prior to treatment.
Contraindications that restrict treatment
Consent for treatment:

I give permission for Miss Melissa, LLC, dba The Nail and Wax Room, (and their associates) to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequense of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

If under 18, please have parent or guardian complete and sign.
Date of Appointment

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Signature
Should be Empty:

Health Information: