Derma Diagnostics, LLC Waiver Form for Professional Strength Peels Because of potential liability problems, we are required to have this form signed and faxed or mailed to our offices before you order any professional strength products. We hope you understand our concern. You Must Be 18 years or older to sign this form: Date:__________________________ Name: _________________________________________________ Company Name (If Applicable) : ____________________________________ Address : ________________________________________________ City, State, Zip: ______________________________________ Phone Number: _____________________ Birth Date : ____________________________ E-Mail Address: __________________________________________________ Product I am purchasing: ___________________________________________ I fully understand that the product I am purchasing is unbuffered and of professional strength, hence, could cause bodily harm. I assume all responsibility for its safe use and proper storage. I am a skin care professional and I am at least 18 years of age. License #_____________________________ Signed: ___________________________________________ Please Print Name :  ___________________________________________