Are you an existing Coconut Village Client? If no, please complete this clients' intake form*YesNoYour Name*Birth date Complimentary service MM DD YYYY an optional question so we can send you a thank you birthday giftAddress* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Email* How did you hear about Coconut Village?What service(s) are you coming in to do?*What are your main concerns with your hands/feet:* Select All Excessive Callus & Dryness on my feet I bite my nails and/or I don't like my hands My Nails are brittle; they break easily I want to treat nail fungus or ingrown nails Just my routine visit - no concerns Type of nail polish used regularly: Gel-polish Dip-powder Gel-nail extension Regular polish NO polish Please choose all that applicable* Currently Pregnant Diabetes History of in-grown Eczema Nail Fungus Epilepsy, Seizure disorder blisters Headaches Chronic or Hepatitis Plantar warts Immune disorders HIV/AIDS Metal bone pins or plates, knee concern Poor circulation Skin disease/skin lesions Any active infection None of the above (Please check all that apply and provide additional information in the space provided) Your Music Comfort Moderately loud low volume Medium volume I'm cool with whatever is playing We are a lively musical spa. We play an eclectic selections of music from Reggae to Saxophone. However, the ambiance is created for your comfort so please select below. If nothing was selected we will believe that you are ok with whatever is playing. Options for Coconut Cove Pedicure or Loving Me Spa* I did NOT book a Coconut Cove Pedicure or Spa Day Upgrade me to Coconut Cove - $25 Upgrade me to Just Me Spa - $45 Yes, I would like to change into a robe Yes, to fresh fruits or a salad I prefer a Sea-food salad Yes to Tea I will choose from your choices of waters If you've booked our Coconut Cove Pedicure, please select all that apply so we can create your spa experience. Or upgrade your Coconut Cove Pedicure $25 moreAdditional Important notes:Masks are no longer required; however, upon a client's request, we will accommodate our clients' comfort. Please use this section to let our staff know if you'd prefer that a mask is used during your service and for any other must-know details to enhance your experience. 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, 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 at 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 agree that ALL pre-paid services and deposits are NON-REFUNDABLE, but will remain on your account for future booking if cancelled within 24hrs of your appointment. I understand that Coconut Village is about care and safety over beauty/looks. I agree with their practice regarding Eponychium (often confused with cuticles). I agree that it is the skin, the living tissue and will not be cut with a nipper, except if the skin is hanging. It’s there to protect the Matrix of my nails from infections and bacteria. 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 if there is a concern. 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 these procedures and accept the potential risks that may occur. I do not hold the aesthetician nor Coconut Village, responsible for any of my conditions that may arrive. I also understand that I am responsible for my pieces of jewelry if they are removed for service. Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.