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Waxing Assessment Form
Have you been seen by a dermatologist?
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?
If yes for how long?
Are you pregnant or lactating?
Have you had any of the following procedures?
Light Chemical Peel
Med/Heavy Chemical Peel
Do you have a history of fever blisters or cold sores?
Are you using any exfoliant or hydroxy-based products?
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