EmailMe Form - Copy of Consultation Form

Copy of Consultation Form

Information provided is kept confidential & used only to provide you with the best service. *Required field

Name *
First Last
Birth Date
MM / DD / YYYY
Allergies *
Yes
No
If yes, please list to what:
Examples: Latex, etc.
Health Conditions *
Eczema
Psoriasis
Diabetes
Arthritis
Peripheral Vascular Disease
Cancer
None
Foot Condition *
Cold Feet
Dry Skin
Cracked Skin
Itchiness
Peeling Skin
Sweaty Feet
Hot Feet
Blisters
Skin Fungus
Nail Fungus
Discoloured Nails
Thick Nails
Tired Legs
Heavy Legs
Foot Odor
Callus Build Up
Corns
Plantar Warts
None
Are you pregnant? *
Yes
No
Are you taking any blood thinning medication (Ex., aspirin) ? *
Yes
No
Preferred Length
Short
Medium
Long
Preferred Nail Shape
Round
Square
Oval
Pointed
Squoval
Preferred Nail Service
Polish
Gel Polish
Preferred Nail Color
None
Clear/Nude/French
Red
Bright
Pastel
Pearlescent
Dark
Nail Art
Have any problems with
Nail Biting
Hangnails
Chipping Nails
Did someone refer you? If yes, who?
Best Days
Sunday
Saturday
Best Time
HH : MM AM/PM

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