BEAUTY SPA

MANICURE AND PEDICURE CONSULTATION FORM

PERSONAL INFORMATION

Full name : _________________________________

Occupation: ________________________________

Address:_____________________________________

Email : _____________________________________

Phone number:______________________________

MEDICAL INFORMATION
Do you have any allergies or sensitivities? Yes or No

Contraindications requiring medical permission

Haemophilia Recent operations of the hands and feet

Medical oedema Arthritis

Diabetes Acute rheumatism

Contraindications that restrict treatment

Cuts Psoriasis

Verrucas Corns

Sunburn Diarrhoea and vomiting

Undiagnosed lumbs and bumps

Nail test

Moisture content: Excellent Good fair Poor

Cuticle condition: Excellent Good fair Poor

Skin condition: Dehydrated Dry Normal

Skin's healing ability: Excellent Good fair Poor

Circulation: Good Normal Poor

Client's declaration: l declare that the information l have given is correct and to the best of my knowledge l can
undertake treatments without any adverse effect.l have been fully informed about contraindications and l am
therefore willing to proceed with treatment.

Client's signature _________________ Date _________________

Therapist signature _______________ Date __________________