Pedicure Intake Form
BellezaxEvelyn
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Are you diabetic?
*
yes
no
Do you have any allergies?
*
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
Never
At Times
Frequently
Cracked Skin
Itchiness
Peeling Skin
Blisters
Skin Fungus
Nail Fungus
Discolored Nails
Thick Nails
Brittle Nails
Callus Build-Up
Plantar Warts
Do you participate in sports/activities in which your nails could be at risk? (For acrylic or extended lengths)
*
Do you wear a lot of closed toe shoes?
*
What improvements would you like to see in your feet?
By checking the following boxes I agree to the policy shown when booking and acknowledge the following:
*
I understand that acrylic toes must be taken special care of and agree to take the necessary precautions to maintain my nail integrity
Due to wearing closed-toe shoes throughout the day, one is more likely to harbor bacteria which may cause “greenies” in the moist, warm space. I understand that a fill/repair/removal is necessary at 4 weeks MAXIMUM or at the first signs of lifting, and agree to either book the professional or safely remove the product by soaking in acetone.
By agreeing to these terms, I understand that I cannot hold BellezaxEvelyn liable for any damage/inconvenience if proper after care was not implemented. I will contact BellezaxEvelyn directly with any questions/concerns regarding the service, results or aftercare.
Signature
*
Submit
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