Pedicure Consultation Form

Name

First NameLast Name

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Select a service

Select an appointment

Do you prefer long or short nails?

ShortLong

Do you have an active lifestyle?

YesNo

Any sports where you mainly use your feet? If yes, kindly indicate them below.

Do you have an existing medical condition that you are treating right now?

Do you have any medical condition listed below?

Are you currently taking any medications? If yes, please list them below.

Do you have any allergies or condition that can affect the procedure?

Are you pregnant?

YesNo

Are you preparing for a special occasion?

YesNo

What products are you using for your hands, nails, and feet?

How did you find about us?

Signature

Date Signed

Date