Your Name*Date of Birth MM DD YYYY Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code What is your skin type: Normal Dry Oily Other Skin typeHave you or anyone in your household traveled in the last 14 days ?YesNoHow did you hear about Coconut Village?Type of nail polish used regularly: Gel Acrylic Dip-powder Regular Other Other nail polishHave you had any of these health conditions in the past or present?* Pregnant or Trying Diabetes History of in-grown Asthma Eczema History of Nail Fungus Seizure disorder Fever blisters Headaches Chronic Hepatitis Herpes Immune disorders HIV/AIDS Metal bone pins or plates Phlebitis, blood clots, poor circulation Blood clotting abnormalities Skin disease/skin lesions Any active infection None of the above (Please check all that apply and provide additional information in the space provided) Additional Important notes:Consent* I agree to the following and have read it carefullyI have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my aesthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I am willing to follow recommendations made by my aesthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the aesthetician immediately. I understand that Coconut Village is about care and safety over beauty/looks and with their practice regarding Eponychium. I agree that it is the skin, the living tissue. It’s there to protect the Matrix of my nails from infections and bacterials. So if the skin is attached to the nail plate it’s still the Eponychium and we DO NOT cut it with a nipper. I understand that the cuticle is the non living tissue that is attached directly to the nail plate and that is what is cleaned up during my manicure. I understand and agree that because they are many uncontrollable factors that contributes to polish chipping Coconut village will do a free re-polish within 3 days from the time the manicure was done. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the aesthetician nor Coconut Village, responsible for any of my conditions that may arrive.EmailThis field is for validation purposes and should be left unchanged.