NAIL SALON CLIENT INTAKE FORM

DISCLAIMER: Thank you for your interest in being a client of [NAIL SALON’S NAME]. Information collected about new clients is confidential and will be treated accordingly.

CLIENT INFORMATION

Name: _____________________ Gender: ☐ Male ☐ Female ☐ Other

Address: ________________________________

E-Mail: _____________________ Phone: ___________

YOUR NAILS

Date of your last professional manicure or pedicure? ___________ 

How often do you get professional manicures and pedicures? ___________

What hand, foot, and nail products do you most frequently use? _____________________________________

How long does your nail or toe polish usually last? __________________________

How would you like to improve your hands, feet, and nails? _____________________________________

What type of hobbies and activities do you do that directly affect your nails? _____________________________________

Do your nails? (select all that apply) ☐ Split ☐ Peel ☐ Crack ☐ Break

Are your cuticles? (select all that apply) ☐ Dry ☐ Torn ☐ Ragged ☐ Inflamed/Red 

Do you bite your nails? ☐ Yes ☐ No

On your hands, do you have? (select all that apply)
☐ Open Wounds ☐ Cuts ☐ Bruises ☐ Tenderness ☐ Rash/Irritation

YOUR HEALTH

Have you ever had or do you now have a nail infection on any of your fingernails or toenails?
☐ Yes ☐ No ☐ N/A
If yes, please provide further information: _____________________________________

Have you experienced any of these health conditions in the past or present?
☐ Diabetes ☐ Hepatitis ☐ HIV/AIDS ☐ Other: __________________

If any of the above are checked, please provide further information: _____________________________________

Are you pregnant? ☐ Yes ☐ No

Do you have any allergies? (including food, medicines, scents, plants, etc.) _____________________________________

READ & ACCEPT

By signing below, you attest that you have provided accurate and current information on this form and answered all medical and health-related questions truthfully and completely. Your signature also certifies that you understand that the above-named salon reserves the right to deny service to any client due to a health condition he or she has that may pose a potential risk to practitioners or other clients, including those that pose a risk of potential contamination to service areas. Furthermore, signing below verifies that you understand that you are responsible for informing the above-named salon or its manicure and pedicure technicians of ANY and ALL changes to your health condition as regards any question on this form or any potential public health risk that may arise from any change in your health condition. You acknowledge and accept that withholding information or providing misinformation may result in contraindications or irritation to the nails and skin from treatments received. The treatments you receive here are voluntary and you release this nail care professional and the above-named salon liability and you assume full responsibility thereof.

SIGNATURE

Signature: _____________________________ Date: ____________________

Printed Name: ____________________