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Contact Us

Personal Information

Emergency Contact

General Health and Medical History

Do you have any medical conditions we should be aware of?
No
If yes, please specify
Have you ever been diagnosed with any of the following?
Do you take any medications that might affect your mobility, balance, or alertness?
No
If yes, please specify
Do you have any allergies (including to products, latex, fragrances, etc.)?
No
If yes, please specify

Mobility and Physical Comfort

Do you use any mobility aids?
Cane
Walker
Wheelchair
Scooter
None
Are you able to get in and out of a salon chair or nail station with minimal assistance?
Yes
No
With help
Do you have any pain, stiffness, or swelling that might affect your comfort during your appointment?
No
If yes, please describe:
Do you experience dizziness, balance problems, or risk of falls?
Often
Sometimes
Rarely
Never

Cognitive or Memory Support

Have you or a caregiver mentioned memory changes or dementia?
Yes
No
Do you sometimes need reminders or help understanding instructions?
Yes
No
Sometimes
Is there anything we can do to make your experience easier or less confusing?
Speak slowly and clearly
Repeat instructions
Quiet environment
Allow extra time
Other

Additional Comfort and Communication

How do you prefer we communicate during your appointment?
Conversational
Quiet
With a caregiver present
Other
Are there any sensitivities we should know about (noise, touch, light, etc.)?
No
If yes, please describe:
Will you have your hair washed prior to our appointment?
Yes
No

Caregiver or Family Input (if applicable)

Signature

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