Date Signed: March 3, 2024
Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.
FACTORS THAT EFFECT SKIN HEALTH
I understand the information I have provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations.