Waxing Assessment Form

Name:

Birthdate:

Occupation:

Address:

City:

State:

Zip Code:

E-Mail:

Phone:

Have you been seen by a dermatologist? Y    N
If yes, for what reason?


Please list all medications that you take regularly.


Do you use Retin-A,Renova, or other topical vitamin A, or hydroquinose? Y    N
If yes for how long?


Are you pregnant or lactating? Y    N

Have you had any of the following procedures?
Laser Resurfacing Y    N

Light Chemical Peel Y    N

Med/Heavy Chemical Peel Y    N

Do you have a history of fever blisters or cold sores? Y    N

Are you using any exfoliant or hydroxy-based products? Y    N

Disclaimer: 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.

Yes, I agree     No, I do not agree