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: Waxing Yes No Last Treatment: Electrolysis Yes No Last Treatment: Laser Re-surfacing Yes No Last Treatment: Chemical Peel Yes No Last Treatment: - - Other Yes No Last Treatment: Dermal Filler Yes No When: Product: Microdermabrasion Plastic/Cosmetic Surgery Yes Yes No No Last Treatment: Where: If yes, how many a day: Product: Area of Face: Brand Name: I attest that the above information is true to the best of my knowledge: Signature:.

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