Client Consultation Form

Client Consultation Form

Please fill out this form prior to your requested service date
Full Name*
Gender*
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address
Have you used our services before*

YesNo
Are you a diabetic
Have you had any broken bones in your feet from current or past injuries?
How many salons have you visited in the last 6-months for a pedicure or manicure service?
Do you currently have foot fungus? If not, have you had it in the past?
Are you on blood thinners?
Have you had any recent or past foot surgeries?
Are you on Blood Pressure Meds?
Have you recently been hospitalized in the last 12-months because of Blood Pressure concerns?
Are you able to lift your legs onto a lounge chair or regular sitting chair for over up to one-hour in order to complete your footcare service?
Do you have a recliner chair where your footcare service can be done?
Are you currently having any hip or leg pain or currently recovering from hip or leg surgery?
Are you okay with receiving a lower leg massage and foot massage as part of your pedicure service?
Would you prefer to use your own lotions or cremes? Or, would you like for us to use our brand?
Are you pregnant?
If you are not the client being serviced answering the questions on this form; please write in your name and relationship to client receiving services.
Have you read our cancelation policy on our website? If not, please review the Q&A section of all the commonly asked questions regarding our products and services. www.thetravelingpedicurist.com
Are you allergic to latex gloves?
Please Sign or Write in your name after filling out this electronic client consultation form.

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