CLIENT CONSENT/ INTAKE FORM
PLEASE READ CAREFULLY AND ANSWER QUESTIONS HONESTLY
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
KEEP ME UP TO DATE WITH BOOKING INFO, FUTURE DISCOUNTS AND MORE
*
YES
NO
Medical History, SELECT ALL THAT APPLY
*
DIABETES
HIGH/ LOW BLOOD PRESSURE
HEART DISEASE
ECZEMA
SKIN CANCER
NAIL / SKIN DISEASE
OTHER
NONE
OTHER LIST HERE
ARE/ DO YOU...., SELECT ALL THAT APPLY
*
Nail Bitter/ picker
Wear tight fitted shoes (pedi service only)
Have damage nails or toenails
NONE
HAVE YOU EVER HAD A NAIL DISEASES?
*
NO
YES
IF SO, LIST HERE
How often do you get your nails done? SELECT ALL THAT APPLY
*
Every 2-3 weeks
Every 4 weeks
Only during holidays & occasions
DO YOU HAVE ANY ALLERGY
*
NO
YES
IF SO, LIST HERE
DO YOU TAKE ANY MEDICATION
*
YES
NO
IF SO, LIST HERE
I UNDERSTAND THAT... (SELECT ALL)
*
EXRTA INFO
PLEASE ENTER VAILD ID RIGHT HERE.
*
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