"Manicure, Pedicure and Artificial Nail Treatment Consultation Information Sheet"

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Manicure, Pedicure and Artificial Nail Treatment Consultation
Contra-indications: Diabetes
: Fungal Infection
: Bruising
: Swelling
Skin Inflammation or infection
To be completed at the time of your first visit
GP Referral
Please indicate whether you currently, or have previously, suffered from the following:
Nail condition, Hands
Thumb
Index
Middle
Ring
Small
Right
Yes
No
Left
Nail condition, Feet
Allergies
nd
rd
th
Big toe
2
3
4
Small toe
Right
Diabetes
Left
Varicose veins
Date
Treatment
Comment
Therapist
Skin conditions such as psoriasis
Bruise easily
Are you, or do you suspect that you are pregnant?
Medication:
Are you currently taking any blood thinning medication?
Are you currently taking steroids?
Are you currently taking antihistamines?
If you have answered YES to any of the above questions treatment may be restricted or
refused and you may be asked to contact your Doctor for advice.
Have you previously had:
Manicure
Acrylic Nails
Pedicure
Fibreglass Nails
Silk Wraps
Gel Nails
Did you suffer any adverse reaction?
Yes
No
Details:______________________________________________________________
-------------------------------------------------------------------------------------------------------
Client Details:
Name___________________________________
D.O.B._____________________
Address______________________________________________________________
Telephone_______________________ e-mail _______________________________
I confirm that I give ________________________ my consent to carry out nail treatments
and that the information given above is correct to the best of my knowledge. I will follow the
verbal and written aftercare advice given to me.
Client signature__________________________________ Date________________
Manicure, Pedicure and Artificial Nail Treatment Consultation
Contra-indications: Diabetes
: Fungal Infection
: Bruising
: Swelling
Skin Inflammation or infection
To be completed at the time of your first visit
GP Referral
Please indicate whether you currently, or have previously, suffered from the following:
Nail condition, Hands
Thumb
Index
Middle
Ring
Small
Right
Yes
No
Left
Nail condition, Feet
Allergies
nd
rd
th
Big toe
2
3
4
Small toe
Right
Diabetes
Left
Varicose veins
Date
Treatment
Comment
Therapist
Skin conditions such as psoriasis
Bruise easily
Are you, or do you suspect that you are pregnant?
Medication:
Are you currently taking any blood thinning medication?
Are you currently taking steroids?
Are you currently taking antihistamines?
If you have answered YES to any of the above questions treatment may be restricted or
refused and you may be asked to contact your Doctor for advice.
Have you previously had:
Manicure
Acrylic Nails
Pedicure
Fibreglass Nails
Silk Wraps
Gel Nails
Did you suffer any adverse reaction?
Yes
No
Details:______________________________________________________________
-------------------------------------------------------------------------------------------------------
Client Details:
Name___________________________________
D.O.B._____________________
Address______________________________________________________________
Telephone_______________________ e-mail _______________________________
I confirm that I give ________________________ my consent to carry out nail treatments
and that the information given above is correct to the best of my knowledge. I will follow the
verbal and written aftercare advice given to me.
Client signature__________________________________ Date________________