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Chemotherapy Patients Consultation Form

"I am a Master Chemo Skin Care Certified with extensive training and experience providing services to chemotherapy patients. I am knowledgeable in the precautions, contraindications, and best practices for performing services such as foot spa pedicure and manicure for chemotherapy patients. I am committed to providing safe and effective care to all of my clients, including those undergoing cancer treatment."

"At The Foot Lady, we recognize the critical importance of infection control when providing services to chemotherapy patients. We take every measure to ensure that our facility and equipment are sterilized and that we adhere to the highest standards of hygiene and safety. We understand that chemotherapy patients are particularly vulnerable to infections, and we are committed to providing a safe and sterile environment for all of our clients. Your health and well-being are our top priority, and we will continue to prioritize infection control to ensure your safety and comfort."

We Sterilize using an autoclave to kill ALL bacterial and fungal organisms. Sterilization with an autoclave is the only means of disease prevention that can be guaranteed.

The sealed pouches are only opened at the start of the service and in the view of the client.

The used pouches and non-sterilized supplies are thrown away by the technician in view of the clients.

We use disposable items, use new file, buffer and pumice stone for each client.

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Important Announcement!
Starting September 2024, we will be updating our store hours, where we will be closed on Sundays and Mondays.

Thank you!
Name:
Phone:
Email:
Birthday:
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May I have your Anticipated appointment date and time?
We offer complimentary drink coffee, tea, or bottled water? For in-spa only, please choose one. Not available on mobile services.
Music preference while in spa.
Do you prefer the Light Massage chair or the Deep Massage chair?
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Do you have your CBC report?
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If yes, please provide details: White blood cells count and Neutrophil percentage.

Have you undergone any chemotherapy or radiation treatment in the past six months?

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When was the last time you have received treatment?
Have you seen a Podiatrist or a Dermatologist before?
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If yes, please provide details: Name or Clinic

Do you have any skin conditions, allergies or sensitivities to products, or any other medical conditions that we should be aware of?

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If yes, please provide details:
Do you have Neuropathy?
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If yes, please provide details where on your foot and legs:
Have you received a foot spa pedicure or manicure in the past?
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Have you been advised by your doctor or healthcare provider to avoid any specific products or treatments?

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If yes, please provide details:
Do you have blisters and rashes on your legs and feet?
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Are your toenails possibly lifting?
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Do you have itchy feet and legs?
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Do you use lotion or cream for moisturizing?
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If yes, please provide details or type of moisturizer:
Will this be a mobile pedicure or IN spa? *
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