Confidential Client History Form

Complete this form if you are NEW or haven't been here in over a year.*
- NEW
- Returning client after a year
At Coconut Village Spa, we are not a factory-like nail shop. We are intentional about your wellness and care. Therefore, no client will be served without a completed intake form. This form protects you and provides us with the necessary information to ensure you receive the best experience and service possible.
First and Last 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*
Is this for a mobile service?
How did you hear about Coconut Village?*

If referred by a friend, family, or another business, please mention their names so we can appreciate them.
What service are you getting done?*
- Facial
- Back Exfoliation Treatment
- Foot Massage
- Nail Extension or Refil
- Pedicure
- Manicure
- Spa Day
- Couples Spa Date
- Self-care Workshop
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
At Coconut Village Spa, we are not a factory-like nail shop. We are intentional about your wellness and care. Therefore, these health-related questions protect you and provide us with the necessary information to ensure you receive the best experience and service possible.
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
- Self-Care Workshops
- Senior Care Virtual Workshop
- Spa Retreat
- Mindset Treatment
- I am ok for now
.
Your Music Comfort*
- Moderately loud
- low volume
- Medium volume
- I’m cool with whatever is playing
We are a lively musical spa, offering a diverse range of music including Reggae, Souls, Gospel, Saxophone, Motown, & R&B. To ensure your comfort, please select your preferred music from the options below. If no selection is made, we will assume you are happy with whatever is playing. Enjoy!
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 to the Coconut Village Staff
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 Disclosure*
I understand
Photos or videos may be taken during or after your service, and these images or videos may be used solely for Coconut Village Spa’s website or social media. The esthetician will ask for your permission before anything is taken or recorded.
Service Cost*
I agree
By booking our services, you agree that you have checked our prices beforehand. If you are paying with a gift certificate, you also agree that you have checked the policy and will mention it when you book.
Customer Satisfaction Policy*
I agree to the Customer Satisfaction Policy.
I agree that if I am not happy with a service, I MUST let the esthetician know before I leave. No client should leave unhappy without letting us know and giving us the opportunity to provide a solution. If a client leaves unhappy and did not tell us, and then leaves a negative review, you agree that we will have it removed by Google, Facebook etc.
Consent*
I agree to the following and have read it carefully
I have provided accurate information about my allergies, prescription drugs, and products I am using. I understand my aesthetician will take precautions to minimize negative reactions. I agree to follow recommendations for at-home care and will consult my aesthetician for any questions or concerns.

I understand that pre-paid services and deposits are non-refundable but can be used for future bookings if a 24-hour cancellation notice was not provided; and that same-day bookings are non-refundable.

I agree with Coconut Village’s practice regarding Eponychium and understand the difference between cuticles and non-living tissue.

I understand that Coconut Village offers a free re-polish within 72 hours if there are concerns about polish chipping.

By signing, I agree to receive information from Coconut Village Spa on marketing promotions, service updates, fee changes, and other relevant updates. I can opt-out anytime.
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.