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 Name Middle Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Birth Date

Day Month Year

Mobile Number *

Area Code Phone Number

E-mail *

Emergency Contact Name *

Mobile Number *

Area Code Phone 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.

What treatments are you interested in?

Treatments

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 attend your appointment alone.

• Please ensure you arrive on time. Not early or late. This allows for no client overlapping and cleaning/disinfecting time.

• 48 hour cancellation notice is required to avoid being charged for your session (unless COVID related).

• Please adhere to the new Potter's Pinkies guidelines at all times (attached).

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

• Please attend your appointment already wearing your OWN face mask/covering.

• Please use the shoe covers provided by Potter's Pinkies before entering the premises.

• Potter's Pinkies now operates a bank transfer only payment system.

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 *

Day Month Year

Full Name *

First Name Last Name

Signature *

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