Manicure, Pedicure and Artificial Nail Treatment Consultation Form Please complete and submit the consultation form below: Fields marked with an asterisk * are required fields Client Name *Telephone (Mobile) Date *Date of Birth Telephone No. (Landline) Email Address Client Address Gender *MaleFemale Please indicate whether you currently, or have previously, suffered from the following: AllergiesDiabetesVaricose veinsSkin conditions such as psoriasisContact DermatitisBruise easilyMedication Are you currently taking any blood thinning medication?Are you currently taking steroids?Are you currently taking antihistamines?Are you, or do you suspect that you are pregnant? Have you previously had: ManicurePedicureGel nailsSilk wrapsNail tipsHand/foot massageAcrylic nailsDid you suffer any adverse reaction *YesNoDetails: Contra-indications: DiabetesFungal InfectionBrusingSwellingInflammation or InfectionIf you have answered YES to any of the above questions treatment may be restricted or refused and you may be asked to contact your Doctor for advice. I confirm I give my consent to carry out nail treatments and that the information given aboveis correct to the best of my knowledge. I have no known allergies to the products discussed with me, and am happy for treatment to proceed without a patch test. Clients signature required during appointment if completing on line NEWSLETTER OPT-OUT If you DO NOT wish to receive further information regarding our special offers or new treatments, please OPT-OUTOPT-OUT VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: