New Client Intake Form

Gloss Nails New Client Intake Form

*Today's Date

*First Name

*Last Name

*Home Address

*Phone Number

*Email

General Health

*Other medications or health conditions not listed:If none, please enter "none"

*Do you have any allergies?

Yes

No

*If YES to allergies, please explain:If you answerd NO please enter "none"

Lifestyle

*Please introduce and tell us a little about yourself so that we may become better acquainted:

*Please list your occupation and any work you perform daily with your hands:

*Are your hands frequently submerged in water or exposed to other chemicals (hand sanitizer, cleaning products, etc)?

Yes

No

*Do you wear gloves when dishwashing, cleaning, gardening, or doing any other other activities that are hard on your hands or fingers?

Yes

No

*Are you active in sports or exercise?

Yes

No

*If YES to sports or exercise, please explain:If you answered NO, please enter "none"

*Please list any other hobbies or activities (sewing, drawing, cooking, crafts, etc):If none, please enter "none"

Hand & Nail

*Have you had any adverse or allergic reaction to any chemicals used in nail services such as acetone, acrylic liquid (monomer), acrylic powders, primers, polishes, etc?

Yes

No

Not sure

*Do you have a problem with lifting, chipping, or peeling of any type of enhancement or polishes?

Yes

No

Not sure

*Have you ever developed an infection of the nails (the "greenies") from any sort of nail enhancement in the past?

Yes

No

Not sure

*Do you have a sensitivity to UV/LED curing (heat spikes)?

Yes

No

Not sure

*Are you a nail biter or polish/enhancement picker?

Yes

No

*Do you take steps at home to care for your hands and nails?

Yes

No

*If YES above, please explain (hand creams, cuticle oils, self filing/trimming nails etc):If none, please enter "none"

*Please describe the current condition of your hands and nails:Dry, brittle, eggshell (thin), ridges, hangnails, thick cuticles, damage, peeling, injury, short, long, normai, etc.

*What types of nail services are you interested in receiving?

Please upload clear, current picture(s) of your hands and nails:Optional, but will be helpful 🙂

*I agree

I have read, understand, and completed this questionnaire truthfully. I am aware that withholding information or providing misinformation may result in undesired results and/or irritation to the skin or nails or other adverse reactions from services received.

*Signature