Confidential Client History Form – Coconut Village Nails Spa

Your Name*

Birth date Complimentary service

MM

DD

YYYY

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Email*

Are you an existing Coconut Village Client? If no, please complete out new clients' intake form*

Yes
No

What is your skin type:

Normal
Dry
Oily
Other

Are you or anyone in your household experiencing Covid symptoms or has been exposed to a person who has been tested positive?*

Yes
No

How did you hear about Coconut Village?

What service(s) are you coming in to do?*

Type of nail polish used regularly:

Gel
Acrylic
Dip-powder
Regular
Other

Other nail polish or concern

Have you had any of these health conditions in the past or present?**

(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 carefully

I 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, expect if the skin is hanging. It’s there to protect the Matrix of my nails from infections and bacterials. 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 my occur. I do not hold the aesthetician nor Coconut Village, responsible for any of my conditions that may arrive.

Date*

Email

This field is for validation purposes and should be left unchanged.