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<br /> <br /> <br /> <br /> <br /> <br />BY SIGNING BELOW, I ACKOWLEDGE THAT I HAVE READ THIS AGREEMENT, I <br />UNDERSTAND IT AND I AGREE TO BE BOUND BY IT. <br /> <br />PRINT FULL NAME: ____________________________ DOB: _________________ <br />ADDRESS: __________________________________________________________ <br />CITY: ___________________________ STATE: ______________ ZIP: __________ <br />PHONE: ______________________________________ <br />EMAIL: _____________________________________________________________ <br />SIGNATURE: _________________________________ DATE: _________________ <br />Procedure Area (Please check and initial): <br />Scalp _______ <br />Beard _______