New Client Consultation Form

Date*

MonthDayYear

Gender

FemaleMale

Name*

First NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

How did you hear about me?*

If Referral, please list name

If Other, please let me know

Emergency Contact (EC)

EC Phone Number

Area CodePhone Number

Date of your last professional manicure or pedicure:

How often do you get professional manicures and pedicures?

What hand, foot and nail products do you most frequently use?

How long does your nail or toe polish usually last?

How would you like to improve your hands, feet and nails?

What type of hobbies and activities do you do that directly affect your nails?

Do your nails (select all that apply)?*

SplitPeelCrackBreak

Are your cuticles (select all that apply)?*

Do you bite your nails?*

YesNo

On your hands, do you have (select all that apply)?*

Have you ever had or do you now have a nail infection on any of your fingernails or toenails?*

YesNoNo, not Applicable

If you checked yes to the question above, please provide further information. If not mark N/A*

Have you experienced any of these health conditions in the past or present?*

If you checked yes to any of these please provide further information. If not mark N/A*

Are you pregnant?*

YesNoNo, not Applicable

Please list any known allergies including food, medicines, scents, plants, etc.:

Read and Accept:*

By signing below, you attest that you have provided accurate and current information on this form and answered all medical and health-related questions truthfully and completely. Your signature also certifies that you understand that Karline's Salon and Spa reserves the right to deny service to any client due to a health condition he or she has that may pose a potential risk to practitioners or other clients, including those that pose a risk of potential contamination to service areas. Furthermore, signing below verifies that you understand that you are responsible for informing Karline's Salon and Spa and/or its manicure and pedicure technicians of ANY and ALL changes to your health condition as regards any question on this form or any potential public health risk that may arise from any change in your health condition. You acknowledge and accept that withholding information or providing misinformation may result in contraindications and/or irritation to the nails and skin from treatments received. The treatments you receive here are voluntary and you release this nail care professional and Karline's Salon and Spa from liability and you assume full responsibility thereof.

Sign and Date*

Consent to Treatment of Minor: By signature below, I also hereby authorize Karline's Salon and Spa to administer service(s) to my child or dependent as they deem necessary.

Signature of Parent or Guardian and Date

Reservation & Cancellation Policy for all current and future appointments: Please do not forget to confirm your appointment. In the event of no shows, cancellations received less than 24 hours prior to appointment Tues-Fri; less than 48 hours prior to a Saturday, Sunday, or private appointment, a $25.00 cancellation fee will incur.*

I understand the reservation and cancellation policies at Karline's Salon and Spa and consent to my credit card on file being charged if I fail to show for my appointment or to give 24 hour notice for appointments scheduled Tuesday through Friday and/or 48 hours notice for Saturday or private appointments. In the event a credit card is not on file, I agree to the addition of a $25.00 fee assessment on my next appointment.

New Client Intake Form

Your Nails and Hands

Your Health