Client Form Full name * First Name Last Name Email Phone (###) ### #### Emergency Contact Name First Name Last Name Phone (###) ### #### Medical or Skin Conditions Please check all which apply. Allergies Diabetes Skin Irritation/inflammation Arthritis Blood Born Disease Hemophilia Broken skin Athletes Foot Nail Infection Calluses Pregnant Occupation or level of activity Are there any special concerns you would like to discuss? Consent Social Media Consent/Release Form For news media, promotional materials, written articles, research and/or photographs I hereby authorized BYSAIRIS to use my photo and/or information related to my experiences. I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, letters to area legislators and media and/or other similar ways. My consent is freely given as a public service to BYSAIRIS without expecting payment. I release BYSAIRIS from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, videotape and/or photographs. I understand that i can revoke this release any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease By signing below, you attest you have provided accurate and current information on this form and answered all medical and health-related questions truthfully and completely. Your signature also certifies that you understand that BYSAIRIS reserves the right to deny service to any client due to a health condition he or she has that may pose a potential risk to practitioners or other client, including those that pose a risk of potential contamination to service areas. Furthermore, signing below verifies that you understand that you are responsible for informing BYSAIRIS and/or its manicurist technician of ANY and ALL changes to your health condition as regards any question on this form or any potential public health risk that may arise from any change in your health condition. **I declare that I have read this consultation form thoroughly and I understand every question asked. I believe I have no medical condition that may affect the treatment. All of the given answer is correct and true to the best of my knowledge. Consent to treatment of minor: By signature below, i hereby authorized BYSAIRIS to administer service (s) tomy child or dependent as they deem necessary Thank you!
