Confidential Client History Form

We are looking forward to pampering you. Are you an existing Coconut Village Client? If no, please complete this clients' intake form*
- Yes
- No
Your Name*
Birth date Complimentary service
Month
Day
Year

an optional question so we can send you a thank you birthday gift
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Email*
How did you hear about Coconut Village?*
What service are you getting done?*
- Facial
- Girls Night Out/Spa Event
- Children Party
- Couples Spa Date
- Pedicure (Coconut Cove, Herbal, Medical, Lifestyle)
- Manicure
- Manicure & Pedicure
Is this for a mobile service?*
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
I would like more info on this/these services.*
- Facials
- Spa Day
- Date Nights
- Group Spa Event
- Manicures/Nail extension
- I am ok for now
Learn more about other services and get a promo gift certificate toward that when you book.
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
- Yes, I would like to change into a robe
- Yes, to fresh fruits or a salad
- I have no, known, food allergies
- 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 more
Additional 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.
Photo Consent*
I agree to the use of image policy.
Photos or videos may be taken during or after your service, and these images or videos may be used solely for Coconut Village Spa websites or social media. If you disagree, please let the Esthetician know.
Consent*
I agree to the following and have read it carefully
I have given an accurate account of the questions above, including all known allergies, prescription drugs, or products I am 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. I will consult the aesthetician immediately if I have additional questions or concerns regarding my treatment or suggested home product / post-treatment care.
I agree that ALL pre-paid services and deposits are NON-REFUNDABLE but will remain on your account for future booking if cancelled within 24 hours of your appointment.
I understand 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 many uncontrollable factors contribute to polish chipping, Coconut village will do a free re-polish within three days from the time the manicure was done if there is a concern.
I agree that this constitutes full disclosure and 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.
By signing this form, you agree to receive information from Coconut Village Spa on marketing promotions, service updates, fee changes and other updates that are relevant to our clients. You can opt-out anytime.
Date*
MM slash DD slash YYYY
Comments
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