Pedicure Consultation Form
Please fill out prior to appointment, all information is confidential and protected.
Client
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is this your first Pedicure?
yes
No
Are you currently Pregnant?
Yes
No
Please list any ingredients you may be allergic to below
Are you prone to ingrown nails?
Yes
No
Have you needed to get a ingrown nail removed in the last 4 months?
Yes
No
Do you have any of the following (select all that apply) :
Arthritis
Diabetes
History of MRSA
Hepatitis A,B or C
Eczema
Other
None of the above
Is there any history I need to be aware of not listed above? If so please fill out below.
If you have a history of MRSA, when was your last flare? Please fill below
Do your nails… (select all that apply)
Split
Peel
Break
Fold
None of the above
Are your cuticles… (select all that apply)
Inflamed/red
Discolored
Ragged
None of the above
Do you have any concerns you’d like to ask about? (Nail issues/skin issues on foot?)
Thank you for your preference!
I value you for helping keep everyone safe and healthy✨ I will be getting back to you as soon as possible to discuss further!!
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