Medical Health Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Medical Health Form

You must be over 18 years of age to complete this form. If you are under 18 years of age, a parent/guardian must complete this form on your behalf, plus the Parental Consent Form.

Why élégant nails need the information and how it is used:

At élégant nails, I take your privacy seriously. For health and safety of clients, I maintain records of any health and/or medical conditions, which may indicate that a particular service or treatment would not go ahead (eg allergies, pregnancy, skin conditions), or a particular product should not be used.

Please note that this form must be kept for a minimum of 7 years from your last treatment for insurance purposes and require clients to complete and submit this form before any treatment takes place. In the case of minors, this will be 7 years AFTER they reach the age of 18.

Clients records from this form are stored on the secure Cloud on Google Forms or on an encrypted computer. Please read the privacy policy at https://elegant-nails.co.uk/policy-documents for more details.

The health records are only used in relation to treatments and service by élégant nails and not used for any other purpose.

Email *

Medical History

You will be asked to review and update this form every 6 months

Do you suffer from any of the following: *

Asthma

Cataracts

Conjunctivitis

Diabetic Retinopathy

Dry Eye Syndrome

Glaucoma

Cancer

Epilepsy

Diabetes

Haemophilia

HIV

Heart Condition

High/Low Blood Pressure

None of the above

Other:

Are you:

Pregnant

Trying to become pregnant

Lactating

Receiving any chemotherapy/radiotherapy

Other:

Have you at any stage in your life had skin cancer, MRSA, herpes cold sores, or skin infections (contagious or not)? *

Yes

Required

Have you used any ACCUTANE products (cystic acne treatment), in the past 12 months? *

Yes

Required

Do you use RETINOL (Vitamin A) products on your face? *

Yes

Maybe

Required

Please list any MEDICATIONS you take: *

Please list anything you are ALLERGIC/SENSITIVE to: *

Name of Doctor/GP: *

Surgery address: *

Is there anything that you’d like to make élégant nails aware of before attending your appointment? *

I can confirm that I have completed this Medical Health Form to the best of my knowledge and understand that if there are any changes to my medical or personal details, I will make my technician aware before further treatment is carried out.

Full Name: *

Address: *

Contact Number: *

Parent/Guardian Name (if required):

Date of completion: *

YYYY

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms