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Pedicure Consultation -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Phone Number

Area Code
Q4

Phone Number

Phone Number
Q5

Email
Q6

Address

Street Address
Q7

Address

Street Address Line 2
Q8

Address

City
Q9

Address

State / Province
Q10

Address

Postal / Zip Code
Q11

Occupation
Q12

Select a service
Q13

Do you prefer long or short nails?
Q14

Do you have an active lifestyle?
Q15

Any sports where you mainly use your feet? If yes, kindly indicate them below.
Q16

Do you have an existing medical condition that you are treating right now?
Q17

Do you have any medical condition listed below?
Q18

Are you currently taking any medications? If yes, please list them below.
Q19

Do you have any allergies or condition that can affect the procedure?
Q20

Are you pregnant?
Q21

Are you preparing for a special occasion?
Q22

What products are you using for your hands, nails, and feet?
Q23

How did you find about us?
Q24

Signature
Q25

Date Signed