Waterless Pedicure Intake
Name
*
First Name
Last Name
Address
Street Address
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Are you diabetic or pre-diabetic? This is very important to know.
*
Yes
No
Do you have any underlying health concerns and do you take any current medications? Blood thinners, acne medications, cancer treatments etc. Please explain or list below.
Are you prone to ingrown nails or have nails that aren't ingrown but do cause discomfort? These may be very curved or very flat or flared nails.
Yes
No
What is your at home care routine for your feet?
Soak
Exfoliate
Moisturize
Nothing currently
Do you have any allergies or sensitivities? Ex: Medications, gluten, soy, coconut, almond, latex, lanolin, chamomile family, citrus etc.
Yes
No
If so, what are you allergic to?
With respect to your feet and legs, which of these conditions do you experience and how often?
Rows
No
At Times
Frequently
Neuropathy
Cancer
Arthritis
Cold Feet
Hot Feet - No sweat
Sweaty Feet
Foot Odor
Callus Build-Up
Dry Skin
Cracked Skin
Peeling Skin
Blisters
Itchiness
Skin Fungus
Nail Fungus
Discolored Nails
Thick Nails
Tired Sensation in Legs
Heavy Sensation in Legs
Corns
Plantar Warts
Damaged Nails
Pregnant
Do you currently see a podiatrist? If so, what doctor?
What are some concerns you have with your feet and what improvements would you like to see?
What improvements would you like to see in your feet?
I agree to photos taken of my feet to document the progress of care in my file and for sharing and educating purposes. All images will be cropped and contain no identifying information.
Yes
No, you may take photos for my file only but please do not share.
I acknowledge that I have read the Salon Policies, Booking and Cancellation Policies. I understand that if I cancel with less than 48 hours notice that I will be charged for HALF (50%) of the service(s). Same day cancellations of less than 24 hours will be charged for the FULL (90%) cost of the service(s) AND may be required to pay a deposit for future appointments.
I agree
A Retainer/(Deposit) Fee is collected for the service(s) to hold the appointment for you. This fee is collected when your appointment is approved and is applied towards your service. The fee is refundable with proper notice given for cancellation or rescheduling. The Retainer/Deposit fee is non-refundable when less than 48 hours or less notice is given of cancellation or reschedule request. Deposit may be moved once when rescheduling at the providers discretion. If you cannot make the second appointment it will be cancelled and retainer forfeit. You will need to pay a new Retainer/Deposit for a new appointment.
*
I agree
I understand that the service(s) I am requesting may include potential risks, such as allergic, chemical, or other adverse reactions, which might cause discomfort, illness, or injury. I voluntarily release the nail technician and place of business from any and all liability for any harm, injury, illness, damage, claims, discomfort, demands, action, and causes of action. I agree to the service and will not hold Kayla Goss or Olivine Natural Salon & Spa responsible for any undesirable outcomes.
Yes, agreed
I understand, have read, and truthfully completed this questionnaire. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin or nails from treatments received. The treatments I receive here are voluntary, and I release Kayla Goss and Olivine Natural Salon & Spa from liability and assume full responsibility thereof.
Yes, agreed
Signature - By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.*
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