Client Intake Form

BLESSED HANDS BY MS. JOY
Full Name*

First NameLast Name
Customer Data Profile
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Occupation
How did you hear about us?*
Birthday (MM/DD)*
What services are you interested in?
Do you have any chronic medical conditions which we should know about?*

YesNo
If so, Please List:
Do you have any allergies to medications, food, herbal or natural supplements?*

YesNo
If so, Please List:
Do you have a preferred appointment day or time?

YesNo
If so, Please provide us with a preferred day, time, and frequency:
Are you smoker?

YesNo
Please tell me about the services you've had in the past.

ManicuresPedicuresAcrylic ApplicationGel ApplicationWrapsLashesWaxingOther
Do you have a preferred nail shape for your natural nails?

RoundSquareOvalSquovalStilettoAlmondRounded SquareOther
Please tell us about your nails and skin (Check all that applies):

Nail BiterWears gloves when cleaningCuticle SensitivityHang nailsNails break easilyDryOilyPrevious or present fungusEczemaPsoriasis
Have you had any recent injury/ries to your hands or feet?

YesNo
If so, Please List:
Signature*
Date*

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

BLESSED HANDS BY MS. JOY