Date of Birth Address CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorra AngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominica What is your skin type:NormalDryOilyOthers Have you or anyone in your household traveled in the last 14 days ?YesNo Type of nail polish used regularly:GelAcrylicDip-powderRegularOther Have you had any of these health conditions in the past or present?*Pregnant or TryingDiabetesHistory of in-grownAsthmaEczemaHistory of Nail FungusSeizure disorder FeverblistersHeadaches ChronicHepatitisHerpesImmune disordersHIV/AIDSMetal bone pins or platesPhlebitis, blood clots, poor circulationBlood clotting abnormalitiesSkin disease/skin lesionsAny active infectionNone of the above (Please check all that apply and provide additional information in the space provided)
