Consent FormClient Information FormConsent FormBefore your appointment…To give you the safest and most comfortable care, we ask all our clients to complete this form. It takes just a couple of minutes and lets us note any health details we should be aware of.Please complete this form for the person receiving the service. If the client is under 18, a parent or legal guardian will need to complete and sign the form.Personal DetailsService Name- Select booked service -Package - Foot Massage + Foot Scrubbing (6 Sessions)Advanced Hand & Nail CareAcrylic Nail Prosthesis CleaningAdvanced Manicure for Children's Deformed NailsAdvanced Manicure for Women and MenAdvanced Pedicure for Children's Deformed NailsAdvanced Pedicure for Deformed NailsAdvanced Pedicure for Deformed Nails & Foot MassageAdvanced Pedicure for Deformed Nails & Nail Plate ProstheticsApplication of a cosmeceutical dressing after cleaning a linear cornCallus Removal on Finger JointsConsultationCorns & CallusesCustom Toe OrthosesDeformed Nail CleaningDeformed Toenails TreatmentFoot MassageFoot Massage & Foot SrubFoot ScrubFoot Skin PeelingHealthy FamilyInstallation of Corrective Nail Systems for Children's FeetLinear Corn TreatmentNail Cleaning for Deformed Nails & Nail ProstheticsNail Plate ProstheticsNail reconstruction "Arcade" & Acrylic InsertsOnycholysis & Onychomycosis TreatmentsPapilloma TreatmentPlasma Treatment for Deformed NailsRemoval of Correction System and Nail CleaningSide Ridge Inflammation & Deformed Toenails TreatmentSoftening of linear corns on the big toe and gentle cleaning after softeningTherapeutic Manicure for Children’s Healthy NailsTherapeutic Manicure for Women and MenTherapeutic PedicureTherapeutic Pedicure & Foot MassageTherapeutic Pedicure & Toenail Correction SystemTherapeutic Pedicure & Waxing Full LegsTherapeutic Pedicure for ChildrenTherapeutic Treatment of Corns and Calluses on Children's FeetToenail Correction SystemTreatment of Calluses on the FootTreatment of Deformed/Broken Toenails with Correction System InstallationWart TreatmentWaxingFull NameDate of BirthGender- Select -MaleFemaleOtherEmailPhoneAddress Line 1Address Line 2 (optional)Town / CityCountyEircodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweParent/Guardian InformationFull NameRelationship to clientPhone/MobileEmailParent/Guardian Health conditionsMedical InformationHealth conditions (tick all that apply) Allergies Diabetes Circulation problems (poor blood flow, varicose veins) Heart conditions Blood clotting disorders Disability Metallic implants, pacemaker, or other electronic medical devices Pregnant or breastfeeding Epilepsy Other relevant conditionsAllergy detailsCirculation detailsHeart detailsClotting detailsDisability detailsImplant DetailsPregnancy stage- If pregnant, please indicate how far along you are -Less than 12 weeks13–24 weeks (Second Trimester)25–36 weeks (Third Trimester)37 weeks or moreBreastfeeding onlyPrefer not to sayOther relevant conditionsCurrent MedicationsAdditional informationPlasma-Specific InfoSkin condition detailsKeloid scarring or poor healing Yes NoRecent Botox/fillers/peels Yes NoRecent treatments detailsActive cold sores/herpes Yes NoPlasma other infoPhoto/Video ConsentI agree that photos/videos may be taken for clinical documentation of my treatment. Yes NoI agree that photos/videos may be used for marketing purposes (website, social media, etc.) Yes NoService ConsentI confirm that I have read and understood the Consent Information and I agree to proceed with the booked serviceI undersand that my personal details may be stored securely and used only for my appointmentsSignature Use your finger or mouse to signParent/Guardian signature Use your finger or mouse to sign.Submit Form This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
