Blushing Rose Intake Form

First Name *

Last Name *

Email *

Phone Number *

Street Address

Street Address Line 2

Postal Code

Occupation

Services you would like *

Nail Extensions

Pedicures

Natural Manicure

Relaxation Massage

Gel Manicure

Waxing

French Gel Manicure

Hard Gel Overlay

Current Health Conditions (Please select all that apply)

Diabetes

Varicose Veins

Skin Disease

Hypertension

Fungal Infection

Bone problems

Pregnancy

Cardiovascular Disease

Hepatitis A

Hepatitis B

HIV

Cancer

Other

Do you have any allergies? *

Yes

No

Have you undergone any surgical procedure? *

Yes

No

Are you currently taking any medications? *

Yes

No

What are your hobbies?

Are you wearing gloves if you clean the house, do the gardening, or washing dishes? *

Yes

No

How do you take care of your hands?

How do you take care of your feet?

Are you currently using or applying products to your nails? If yes, please list the name of the products below

When is the last time you had a professional nail service?

How often do you go to a nail salon?

Nail condition (Please select all that apply)

Split

Peel

Crack

Cuticle condition (Please select all that apply)

Dry

Torn

Inflamed

Do you have any cuts or wounds in your hands or feet? *

Yes

No

Are you preparing for a special occasion? *

Yes

No

Client Signature *

Date Signed *

Intake Form

Client Information

Health History

Nail Care Questions

Client Agreement