Mobile Spa Nail Treatment

Thank you for taking the time to fill out this form for the upcoming treatment. We’re looking forward to providing you with the ultimate spa experience. All of the information provided is confidential and will only be shared with the technician performing your service. Your privacy and safety is our utmost concern. Please feel to contact us if you have any questions.

Nail Service Intake Form

Service Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Medical History
1. Are you currently under the care of a Physician?*
- Yes
- No
If yes, for what?
2. Are you taking any medications?*
- Yes
- No
If yes, please list medication and what its for (Example: Albuterol - Asthma)
3. Are you pregnant?*
- Yes
- No
If yes, how far along? Risk factor (low, med, or high)?
4. Are you on birth control or hormone replacement therapy?*
- Yes
- No
If yes, please list name?
5. Have you ever had an allergic reaction to cosmetics, food, drugs, or flowers?*
- Yes
- No
If yes, please explain?
6. Please check any of the following conditions that you have*
- Asthma
- Anxiety
- Arthritis
- Blood Cots
- Cancer
- Diabetes
- Depression
- Dermatitis
- Eczema
- Epilepsy
- Fibromyalgia
- Heart Attack
- Headaches/Migraines
- Hysterectomy
- Immune Disorder
- Infectious Disease (i.e. HIV)
- Joint Replacement
- Kidney Dysfunction
- High Blood Pressure
- Low Blood Pressure
- Lupus
- Neuropathy
- Numbness
- Skin Disease/Disorder
- Stroke
- Sprain/Strain
- Sinus Problems
If yes, please explain?
Nail Health & Therapy
1. Have you had any adverse or allergic reaction to any chemicals used in nail services such as acetone, acrylic liquid (monomer) acrylic powders, polishes, etc?*
- Yes
- No
2. What type of nail services or enhancements have had in the past? (please check all that apply)*
- Manicures
- Pedicures
- Paraffin treatment
- Gel polish
- Regular Polish
- Ridge Filler
- Acrylic/Dip nails
- Wraps (silk, fiberglass)
- Hard gel
- Builder/Structure gel
- Extensions/overlays
- Press-ons
- Full cover gel extensions
3. Do you have a problem with lifting, chipping, or peeling of any type of enhancement or polishes?*
- Yes
- No
4. Have you ever developed an infection of the nails (the greenies) from any sort of nail enhancement in the past?*
- Yes
- No
5. Do you have a sensitivity to UV/LED curing (heat spikes)?*
- Yes
- No
6. Are you a nail biter or polish/enhancement picker?*
- Yes
- No
7. Do you take steps at home to care for your hands, feet, and nails?*
- Yes
- No
If yes, please explain (hand creams, cuticle oils, self filing/trimming nails, etc):
8. Please describe the current condition of your nails, hands and/or feet (dry, brittle, eggshell (thin), ridges, hangnails, thick cuticles, damage, peeling, injury/damage, short, long, normal, etc.)
9. Would you like to be contacted to create a nailcare regimen for home use?*
- Yes
- No
Policy & Consent
I hereby grant Synergy Skin Care Spa, LLC and authorized representatives to use and/or apply any necessary products as part of the service I am receiving. I understand that nail products may contain reactive chemicals which may result in an allergic reaction. By receiving service, you hereby assume all risk of personal injury that you may sustain as a result of the application of any products used, the manner of service rendered, including but not limited to the application of chemicals, and use of appliances or implements to perform the service. Consult Synergy Skin Care Spa, LLC immediately if problems occur. Be sure to ask the technician if you have any questions or concerns related to the treatments or post-treatment care. Due to the high-risk nature of some medical conditions, it may be necessary to obtain a doctor’s release or permission before receiving treatment. I agree to inform the therapist of any experience of pain or concerns before, during and/or after the treatment. I further understand that services provided are NOT a substitution for a medical examination, diagnosis or treatment by a medical or chiropractic physician or other healthcare specialist.
Informed Consent*
- I understand that Synergy Skin Care Spa, LLC and its authorized representatives reserve the right to cancel or reschedule my appointment if I present with any nail or health conditions that my may be contraindicated for receiving nail services. I understand that it is out of the scope of the nail technician to diagnosis health conditions or to give any medical advice.
- I understand that Synergy Skin Care Spa, LLC and its authorized representatives may cancel or reschedule my appointment if I did not provide notification of the need to have dip and or gel removed prior to my appointment.
- I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the nails, diet, smoking, and climate.
- I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Synergy Skin Care & Spa.
- I have revealed any medical condition that may affect the treatment such as athletes foot, fungus or warts, pregnancy, allergies, surgery, types of contraindicated medical conditions.
- I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Synergy Skin Care & Spa and its authorized representatives.
Photography Policy*
I agree to the photography policy.
I give permission for photographs to be used by Synergy Skin Care & Spa for educational and/or promotional purposes. Complete client confidentiality will be maintained at all times.
Name*
First Last
I have read and fully understand the terms within the above policies and consent. All my questions have been addressed to my satisfaction. I certify that all of the above information is true and to the best of my knowledge. I understand and agree with the policies. By signing this form, I waive any and all claims, damages, action and liabilities against Synergy Skin Care & Spa arising out of or relating to massage therapy, hand/foot treatments (including manicure & pedicure services), skincare and allergic reactions to services performed. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am eighteen years of age (18) or older.
Date*
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Mobile Spa Nail Treatment

Nail Service Intake Form

Medical History

Nail Health & Therapy

Policy & Consent