NEW CLIENT CONSULTATION FORM

Client's Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred/Best Form of Contact

Best time(s) to reach you?

Occupation

Service(s) you would like to try (please select all that applies):

Current Health Conditions (please select all that applies):

Other health condition(s)/concerns you would like to inform your service provider?

Please list any health conditions not listed above.

Do you have any known allergies?

Please list below the type of allergies that you have

Have you ever had any adverse/allergic reactions to any products/chemicals commonly used in nail services?

If yes, please describe reaction(s) and list product(s).

ie: latex, formaldehyde, acetone, fragrance/scents, liquid monomer, resins, solvents etc.

Are you currently taking any medications?

Please list them below including vitamins and supplements

List any hobbies/daily activities that involve the use of your hands and/or feet

Are you wearing gloves if you clean the house, do the gardening, or washing dishes?

If applicable, how do you take care of your hands/nails?

If applicable, how do you take care of your feet/toenails?

Are you currently using or applying products to your nails? If yes, please list the name of the products below

ie: lotions, oils, polish, etc

When was the last time you received professional nail service(s)?

How often do you receive professional nail service(s)?

Nail Condition (Please select all that applies):

Cuticle/Skin Condition (Please select all that applies):

Do you currently have any cuts, wounds, and/or broken skin on your hands and/or feet?

If yes, where?

Are you preparing for a special occasion?

Would you like to receive promotions and offers via email?

If you are under 18 years old, a legal guardian/parent required to review entire form, provide consent, agree to all terms, and provide signature.

By signing below, I confirmed that all information I entered in this form is accurate and true. I also authorized the service provider at MERAKI BEAUTY LLC to perform nail care service(s) to my hands and feet.

Sign By

First NameLast Name

Relationship to Client

Self, Legal Guardian/Parent

Signature

Date Signed

Date

NEW CLIENT CONSULTATION FORM

Health History

Nail Care Questions