Hair Density Waiver

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Name *

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Last

Phone *

Date of Birth *

Email *

Address *

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Medical History (Select all that apply) *

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

Other (please specify):

Please specify / Include doctors information

Please Explain:

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

Price Per Session

$ 0.00

Procedure and Chana’s Beauty’s obligations

Cancellation Policy

Risk Factors

Client’s Obligations, Representations and aftercare requirements

Outcome

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Pictures

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Date / Time *

Date

Time