Salon Pedicure, Manicure Health Intake Form Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Date

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  Name

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  May your service provider call you by your first name?

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  Is this your first Spa/Salon Service ever?

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  What are your goals for this treatment?

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  Have you ever had a negative reaction to any skin care product?

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  (If yes, please explain)

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  Do you have any open wounds?

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  If yes, please describe.

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  Are you pregnant?

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  If yes, please enter the number of weeks:

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  Are you wearing contact lenses?

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  Do you have any allergies?

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  If yes, please describe.

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  If you are receiving a Massage or Body Treatment, do you have or have you had:

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  Any numbness or stabbing pains

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  High blood pressure – Are you currently taking medication?

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  Asthma

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  Claustrophobia

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  Any injuries to the lymphatic system

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  Broken bones in the past two years

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  Do you have any infections or fever

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  Congestive heart failure, CHF or other cardiac problems

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  If you answered YES to any of the above, please describe:

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  If you are receiving a Facial, are you on any of the following medications?

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  Accutane

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  Retinal

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  Do you have any skin conditions or breakouts you are concerned about?

• ...and More!