Your Name* Birth date Complimentary service Month Day Year Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon 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?** Currently Pregnant or Trying Diabetes History of in-grown Asthma Eczema History of Nail Fungus Seizure disorder Fever blisters Headaches Chronic Hepatitis Herpes Immune disorders HIV/AIDS Metal bone pins or plates Phlebitis, blood clots, poor circulation Blood clotting abnormalities Skin disease/skin lesions Any active infection None of the above (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 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, 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* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.