Hair Density Waiver

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Medical History (Select all that apply) *

Have you been under a dermatologist's care within the past year? *

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Have you ever had an allergic reaction to any of the following? *

Within the past 3 months, have you used Retin-A, Renova, AHAs or Retinol/Vitamin A-derivative products? If yes, please describe: *

Price and Payment

Service Agreement

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Date / Time *

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