Waxing Intake Form Contact Information Name Street Address City State Zip Code Home Phone Work Phone Cell Phone E-mail Address Emergency Contacts Primary Physician Physician Phone Emergency Contact Name Emergency Contact Phone Emergency Contact Relationship Biometric & Health Information Age Occupation List any medications and their purpose Do you use Retin-A,Renova, or other topical vitamin A, or hydroquinose? YesNo If yes, for how long? Are you pregnant or lactating? YesNo Have you had any of the following procedures? Laser ResurfacingLight Chemical PeelMed/Heavy Chemical Peel Do you have a history of fever blisters or cold sores? YesNo Are you using any exfoliant or hydroxy-based products? YesNo Completion Were you Referred? YesNo If yes, By Whom? How did you find me? GoogleOther Search EngineTwitterFacebookLinkedInOther If "Other", please specify Dan Chisholm is not responsible for any injury or allergic reaction(s) on any skin abrasion as a result of the service(s) on premise. I understand that all services are performed with my informed consent. I have read and understand the above statement