Client Consult Form and Release for Services
Note: You can email or bring a copy of this consult form (completed and signed) with you on your vist or we will have you fill one out upon arrival of your 1st appointment. Our email address is: salonnailsbychana@yahoo.com
1. Do you have any medical conditions that I should be made aware of? If so, briefly describe what your condition is. All information is kept confidential
2. Have you had any foot or fingernail fungus in the past 6 months? Yes or No
3. Prior to coming here for today’s visit, how many different nail salons have you gone too in the last 3 month’s? ___________________________
4. Do you have any allergens/allergies? Yes or No
5. Are you diabetic or insulin dependent? Yes or No
6. Are you on any blood thinners? Yes or No
7. What type of services do you normally get: Natural Nail Care, Pedicures or Artificial Nail Services? Circle one or more of the answers provided.
8. Are you nails sensitive? Yes or No
9. Are you on Dr's orders? Yes or No
10. Are you on any type of medications that I should know about? Yes or No
Explain here______________________________________
11. Have you had any surgeries on your hands or feet? Yes or No
Explain here______________________________________
Please provide us with your:
Email address: _________________________________
Telephone Number:____________________________________
Home Address (for coupons): ________________________________________________________
Sign and Date on the line below: