Confidential Consultation Card Manicure / Pedicure
ADVERTISEMENT
1CONFIDENTIAL CONSULTATION CARD
MANICURE / PEDICURE
NAME: ______________________________________________________________________
ADDRESS: ___________________________________________________________________
CITY: ____________________________________
POSTAL / ZIP CODE: ___________________
PHONE: (H) (_____)_____ __________
(B) (_____) _____ ___________
EMAIL ADDRESS:_____________________________________________
REFERRED BY______________________________DATE OF BIRTH (M/D/Y)__________________
GENERAL HEALTH RECORD
1.
Have you ever had a manicure or pedicure before?
Yes ¨
No ¨
If Yes, how often?
2.
Do you have any allergies?
Yes ¨
No ¨
If yes, please describe.
Yes ¨
No ¨
3.
Do you have and ingrown toenail?
4.
Do you have athlete’s foot?
Yes ¨
No ¨
5.
Do you feet perspire?
Yes ¨
No ¨
If Yes, how often?_____________________________________
6.
Do you have nail fungus?
Yes ¨
No ¨
If yes, are you taking any medication for this condition?
Yes ¨
No ¨
7.
Do you have planter’s warts (feet and hands)?
If yes, are you taking any medication for this condition?
8.
Do you have any health conditions that could affect your
Yes ¨
No ¨
Treatment or that we should be made aware of?
If yes, please explain. ____________________________________
Personal Information Consent
The information on this form is collected to assist us in identifying any conditions, which could affect your
treatment. If the information on this form changes, please let us know prior to your next treatment. The
information on the form is treated as confidential and will not be disclosed to any third parties unless we are
required by law to do so.
Signature: _____________________________________
Date: ______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business