TSNC Resident Enrollment for Non-Medical Nail Care
Share resident and family details to request non-medical nail care for your loved one.
Resident Information
Resident Full Name
*
First Name
Middle Name
Last Name
Facility / Community Name and City
*
Resident Room Number
Family / Responsible Party Contact
Full Name
*
First Name
Middle Name
Last Name
Relationship to Resident
*
Please Select
Spouse
Child
Parent
Sibling
Grandchild
Guardian
Friend
Other
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Emergency Contact, if different from above
Service Request and Care Preferences
Requested Service
*
Basic Nail Care
Basic Feet Care
Combination (Hands & Feet)
Would you like moisturizer included?
Yes
No
Interest in nail color or polish
Birthdays
Holidays
Special occasions
Not at this time
Other
Mobility or comfort considerations
Allergies, sensitivities, or additional notes
Consent and Acknowledgment
I consent to:
*
Recurring services
One-time service
Typed name / signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Request Care
Request Care
Should be Empty: