Pedicure Information Form
Meet Your Feet
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you diabetic?
*
yes
no
Do you have any allergies?
yes
no
If so, what are you allergic to?
With respect to your feet and legs, which of these conditions do you experience and how often?
Never
At Times
Frequently
Cold Feet
Dry Skin
Cracked Skin
Itchiness
Peeling Skin
Sweaty Feet
Hot Feet
Blisters
Skin Fungus
Nail Fungus
Discolored Nails
Thick Nails
Tired Sensation in Legs
Heavy Sensation in Legs
Foot Odor
Callus Build-Up
Corns
Plantar Warts
Do you currently see a podiatrist? If so, what doctor?
What are some concerns you have with your feet? (pain/discomfort)
What improvements would you like to see in your feet?
Submit
Should be Empty: