Potter's Pinkies Client Health Questionnaire

Client Health Questionnaire

All information is held in the strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Full Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

DayMonthYear

Mobile Number*

Area CodePhone Number

E-mail*

Emergency Contact Name*

Mobile Number*

Area CodePhone Number

Occupation

Doctors name*

Doctors phone number*

Surgery name and address*

Medication and allergy history

Please list all medications*

Please list any known allergies*

Have you ever suffered from over exposure/or reaction to any nail products? If yes please give full details below*

Are you suffering from any fresh bruising or pain in the hands, lower arm, lower legs or feet? Applicable for spa/deluxe manicure/pedicure only.*

Are you currently or have you recently suffered from any fungal infections? Please give full details below.*

YesNo

If you have had COVID-19, on what date did the symptoms start?

Date

YesNo

Please state date of first vaccine.

Date

Please state date of second vaccine (if known).

Date

Which vaccine did you receive?

Did you suffer any adverse side effects from the vaccine?

Please list side affects above

What treatments are you interested in?

Treatment Policies:

Client services and chart information are confidential. Written authorisation is required from you to release any information.

• Please bring minimal personal belongings with you and refrain from touching them whilst your treatment is in progress.

• Please ensure you arrive on time.

• Please note I have a 48 hour cancellation period, if you cancel your appointment after this time, full payment will be required.

• Please adhere to Potter's Pinkies guidelines at all times.

• If you arrive more than 10 minutes late Potter's Pinkies reserves the right to reschedule your appointment.

• Payments can be made using cash, card or bank transfer.

Client Agreement:

I understand that Potter's Pinkies cannot advise medically on skin conditions or health issues but they can advise I seek medical advice from my GP and have the right to refuse treatment if deemed necessary.

It is my choice to visit Potter's Pinkies for my nail treatment(s).

I understand that the treatment given is designed to best suits my needs, based on this form and our consultation prior to treatment commencing.

I also understand that if I have omitted any information from this form it is my responsibilty and I do not hold Potter's Pinkies responsible in any way should something happen.

I have filled this questionnaire in to the best of my knowledge at the time of signing and understand it is my responsibility to update Potter's Pinkies immediately should anything change.

I understand that my failure to do so may pose a threat to my health and physical well being and I will not hold Potter's Pinkies responsible for any liability whatsoever arising from failure on my part.

By electroncally signing below, I agree to the treatment policy and client agreement above.

Date*

DayMonthYear

Full Name*

First NameLast Name

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.