Date
Salon name_______________________________________________________________
Address:
City, State, Zip____________________________
Salon Phone
Nail Tech/Cosmetologist __________________________________
Client’s name____________________________________________________
I am referring my client for possible medical attention because I observed one or more of the following:
___
___
___
___
___
___
___
Redness around the nail, foot, hand, fingers, toes
Skin problem, itching or rash
Nail discoloration
Nail pain
Foot pain
Painful, thick skin or corns
Swelling on the hand, foot, finger, toe
___ “Not normal” appearance
___ Nail(s) lifted from the nail beds
___ Nail Thickness
___ Thin or brittle nails
___ Problem from acrylic, gel nails, nail wraps
___ Skin Reaction to a beauty product
___ Accidental injury with nail care instrument
Dear Doctor
I greatly appreciate you seeing my client and examining
her for the above potential problem. If you determine she can continue my services, I have sent her with a form
you can use to authorize her return with any restrictions or instructions. Thank you for your assistance
Signature of Nail Technician or Cosmetologist ________________________________________________________
Date
Salon name_______________________________________________________________
Address:
City, State, Zip____________________________
Salon Phone
Nail Tech/Cosmetologist __________________________________
Client’s name____________________________________________________
I am referring my client for possible medical attention because I observed one or more of the following:
___
___
___
___
___
___
___
Redness around the nail, foot, hand, fingers, toes
Skin problem, itching or rash
Nail discoloration
Nail pain
Foot pain
Painful, thick skin or corns
Swelling on the hand, foot, finger, toe
___ “Not normal” appearance
___ Nail(s) lifted from the nail beds
___ Nail Thickness
___ Thin or brittle nails
___ Problem from acrylic, gel nails, nail wraps
___ Skin Reaction to a beauty product
___ Accidental injury with nail care instrument
Dear Doctor
I greatly appreciate you seeing my client and examining
her for the above potential problem. If you determine she can continue my services, I have sent her with a form
you can use to authorize her return with any restrictions or instructions. Thank you for your assistance
Signature of Nail Technician or Cosmetologist ________________________________________________________