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First name

Last name

Email

Phone

I agree to contacted via phone or email.

Please tick any of the condtions you have:

Abdominal/ Digestive problems

Allergies

Arthritis

Asthma or lung conditions

Blood clots

Cancer / Tumors

Chronic Fatigue

Chronic pain

Depression

Diabetes

Fatigue

Fibromyalgia

Headaches or migraines

Hearing problems

Heart, circulatory problems

Hernias

High / Low blood pressure

Infectious disease

Lymph node removal

Motor vehicle accident / trauma

Muscle or joint pain

Muscle, bone injuries

Numbness or tingling

Phlebitis

Pregnancy

Rash, athletes foot/tinea

Seizures

Skin disorders

Stroke

Varicose veins

Vision problems/contact lenses

Other

None

Pigmented lesions

Recent cosmetic injectable treatments

Recent IPL or Laser

Post- surgery wound healing

Open skin

Undiagnosed lumps

Hepatitis

HIV

Other conditions not listed above:

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 which affect your nails?

Do you bite your nails?

Yes

No

Have you ever had or do you now have a nail infection on any of your fingernails or toenails? If so, please explain:

Yes

No

If yes, please explain:

Please note the potential risks to nail treatments:

Bacteria and fungus can spread through dirty water or tools and cause painful skin rashes or yellow nails

Cutting cuticles or skin creates small wounds that let germs enter the body and cause swelling

Harsh chemicals and constant filing make the natural nail plate thin, brittle, and prone to breaking

Polishes and lotions can cause itchy red allergies while UV lamps may cause long term skin damageMedical SafetyPeople with diabetes face a higher danger be

I understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for my treatment.

I understand the potiential risks and adverse reactions of the treatment.

Signature

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