Waxing Form - Fitness and Massage Chicago

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

(314) 580-2051

5224 N Winthrop Ave
Chicago, IL 60640