Brand: We Love Skin

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To most quickly and accurately process your prescription, please fill in the details here. Our product concierge team will verify all information with your provider.

**PLEASE NOTE: We are only authorized to sell RX products to patients who have been seen by a BACD provider in the past two years. If you have not been seen by a BACD provider in this time frame, your order will be refunded to the original form of payment. We thank you for your understanding.

Product name

Name*

Last Name*

Email*

Date of Birth*

Are you currently pregnant, planning on becoming pregnant or breastfeeding?*

1. Describe any medical conditions you have had in the past or are currently being treated for. If no medical conditions, enter "none":*

2.List any medications you are taking (including eye drops). If no medications, enter "none":*

3. List any allergies to medications. If no allergies, enter "none":*

Please provide the best phone number in case we need to contact you to confirm any information.

I accept responsibility for any and all adverse side effects that may occur. I hereby release Bay Area Cosmetic Dermatology and WE LOVE SKIN STORE of any liability in connection with use of this product.

I waive the option to be seen in person for medical evaluation and hereby certify all information I've provided is true and correct. I understand I am purchasing a prescription product which is a final sale and cannot be returned.

Brand: We Love Skin

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