Title

Full Name

Please State Your Age

Mobile Phone Number

Email Address

Address Of Residence

Occupation

Duties

Type of Service? Type of Service? Home Service Walk In

Are You Currently Taking Any Medication Are You Currently Taking Any Medication Yes No

If Yes Please Provide More Information

Do You Have Any Allergies? Do You Have Any Allergies? Yes No

If Yes Please State Information

Do You Have Any Health Condition? Do You Have Any Health Condition? Yes No

If Yes Please State Information

Are You Pregnant? Are You Pregnant? Yes No

Do You Have Any Cuts/Wounds In Your Hands or Feet Do You Have Any Cuts/Wounds In Your Hands or Feet Yes No

If Yes Please State Area

Do You Pick or Bite Your Nails? Do You Pick or Bite Your Nails? Yes No

If Yes Please State Infomation

Do You Have Any Skin Condition? Do You Have Any Skin Condition? Yes No

If Yes Please State Infomation

Do You Play Any Sports? Do You Play Any Sports? Yes No

If Yes Please State Infomation

Do You Smoke? Do You Smoke? Yes No

If Yes Please State How Many Cigarettes A Day

Have You Ever Experienced Any Allergic Reactions To Any Nail Care Products In The Past? Have You Ever Experienced Any Allergic Reactions To Any Nail Care Products In The Past? Yes No

If Yes Please State Reason

Type Of Treatment You Are Applying For: Type Of Treatment You Are Applying For: Manicures Acrylic Manicures Builder Gel Pedicures Full Package BIAB

Other Information On Treatment

In filling in this assessment form it is understood you have you have given full information about yourself. All information will be kept strictly private and confidential. I understand to increase longevity and the quality of the nails, I must follow the after care procedure. In filling in this assessment form it is understood you have you have given full information about yourself. All information will be kept strictly private and confidential. I understand to increase longevity and the quality of the nails, I must follow the after care procedure. I Agree

I/We declare that the information provided in this application and in enclosed documents is true to the best of my/our knowledge and belief that no material face relation to this application has been knowingly withheld. I/We declare that the information provided in this application and in enclosed documents is true to the best of my/our knowledge and belief that no material face relation to this application has been knowingly withheld. I Declare

Signed Full Name

Signed Date