Be sure to complete and submit the form below as well as the Disclosure & Consent form at least one week prior to your appointment. We suggest you submit it when you book your appointment.
Please read and complete the following information carefully and in its entirety.
Are you now or have you been under the care of a physician within the last two years? If yes, please provide the physician's name, address, and phone number. *
Condition being treated:
List all medications you are currently taking, including Retin-A, Glycolic Acid, and Accutane.*
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