Manicure And Pedicure Intake Form - Integrative Life Solutions (Page 2 of 2) in pdf

Manicure And Pedicure Intake Form - Integrative Life Solutions Page 2

Have you ever been diagnosed with an infectious disease, including any of the following:

AIDS HIV Hepatitis A or B

If so, please explain: _______________________________________________________

Please list any known allergies, such as to food, medicines, scents, plants/grass/trees,

etc.: ___________________________________________________________________

Please list any medications you take, including oral, topical, blood thinners, pain

relievers, etc.:____________________________________________________________

By signing below, you attest that you have provided accurate and current information

on this form and answered all medical and health-related questions truthfully and

completely. Your signature also certifies that you understand that Integrative Life

Solutions, Inc. reserves the right to deny service to any client due to a health condition

he or she has that may pose a potential risk to practitioners or other clients, including

those that pose a risk of potential contamination to service areas. Furthermore, signing

below verifies that you understand that you are responsible for informing Integrative

Life Solutions and/or its manicure and pedicure technicians of ANY and ALL changes to

your health condition as regards any question on this form or any potential public health

risk that may arise from any change in your health condition.

Print Name _____________________________________________________________

Signature_______________________________________________________________

Today’s Date____________

Manicure And Pedicure Intake Form - Integrative Life Solutions Page 2