Client Intake & Liability Waiver Form for PediCare Professionals

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth
Date
Month
Day
Year
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email Address* This field is required.
example@example.com
5
Service Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Emergency Contact Name
7
Emergency Contact Phone
Please enter a valid phone number.
8
Do you currently have or have you previously been diagnosed with any of the following conditions?
9
If yes, please provide details.
10
Select any foot health issues you have:
11
Please describe any current foot concerns.
12
Select any pain or sensitivity issues:
13
Select any allergies or sensitivities:
14
Additional allergy details:
15
Select any mobility considerations:
16
Which service are you scheduling?* This field is required.
Essential Care Trim
Circulatory Boost Pedicure
17
Do you have any service preferences?
Unscented products
Light massage
No massage
No preference
18
Liability Waiver* This field is required.
By signing below, I acknowledge that I have read, understood, and agree to the Client Intake and Liability Waiver for PediCare Professionals. 

I understand that PediCare Professionals provides professional waterless wellness pedicure services that are cosmetic and hygiene-focused in nature. These services are not medical treatment and are not a substitute for care provided by a licensed medical professional or podiatrist. 

I agree to disclose all relevant health conditions, including but not limited to diabetes, circulatory issues, infections, wounds, or sensitivities prior to service. I understand that failure to disclose such conditions may increase the risk of adverse outcomes. 

I understand that PediCare Professionals reserves the right to modify or refuse service if any condition is present that may pose a health or safety risk. 

I acknowledge that, while all reasonable precautions and sanitation protocols are followed, there are inherent risks associated with foot care services, including but not limited to minor skin irritation, sensitivity, or accidental nicks. 

I agree to immediately inform the practitioner of any discomfort during the service so adjustments can be made. 

I understand that results may vary and that no guarantees have been made regarding outcomes. 

To the fullest extent permitted by law, I voluntarily release, waive, and hold harmless PediCare Professionals and its practitioner from any liability, claims, or damages arising from services provided, except in cases of gross negligence or willful misconduct. 

I confirm that I am voluntarily receiving services and assume all associated risks.
19
I have read and agree to the Client Intake and Liability Waiver for PediCare Professionals.* This field is required.
20
Client Signature* This field is required.
21
Date* This field is required.
Date
Month
Day
Year
22
Email Address Confirmation* This field is required.
example@example.com
Confirm Email
23
Notification Email to PediCare Professionals* This field is required.
example@example.com
24
Signed Waiver PDF Copy* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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Cancelof
25
Appointment Policy AcknowledgmentI understand that PediCare Professionals operates on a scheduled appointment basis. I agree to provide at least 24 hours’ notice for cancellations or rescheduling. Late cancellations or no-shows may result in a cancellation fee or refusal of future service.
I understand and agree to the cancellation policy
26
Photo Consent (Optional)I consent to PediCare Professionals taking photos of my feet for documentation, quality assurance, and optional marketing purposes. No identifying information will be shared.
I consent to photos for internal documentation only
I consent to photos for marketing use (no identifying information)
I do not consent to photos
Should be Empty: