Manicure And Pedicure Intake Form - Integrative Life Solutions printable pdf download

Manicure And Pedicure Intake Form - Integrative Life Solutions

Manicure and Pedicure Intake Form

Full Name: _______________________________________

Date: ________________

Address: ________________________________________

City/State______________________________________ ZIP Code__________________

Phone: _______________________________

Date of Birth: _____________________

E-mail Address: ___________________________________________________________

Emergency Contact: ____________________________ Phone: ____________________

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How did you hear about Integrative Life Solutions? ______________________________

Date of your last professional manicure or pedicure _____________________________

How often do you get professional manicures and pedicures? _____________________

What hand and nail products do you most frequently use?

________________________________________________________________________

How long does your nail or toe polish usually last? _______________________________

For the questions below, when applicable please circle all the answers that apply:

Do your nails: Split Peel Crack Break

Are your nails: Too Soft Too Hard

Are your cuticles ever: Dry Torn Ragged Inflamed Red

On your hands/feet, do you have: Calluses Corns Ingrown Nails Warts Athlete’s Foot

Does the skin on your hands or feet ever: Crack Break Open Bleed

On your hands or feet, do you have: Open Wounds Cuts Sores Bruises Tenderness

Are you diabetic? Y N

Are you pregnant? Y N

Have you ever had or do you now have a nail infection on either your fingernails or

tonenails? If so, please explain: ______________________________________________

How would you like to improve your hands, feet, and nails?

________________________________________________________________________

Manicure And Pedicure Intake Form - Integrative Life Solutions