Consent for Electronically Accessing Pharmaceutical Information

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The information will be used to evaluate any role that the medications that I am taking may play in my skin and overall health, as well as any possible interactions with medications that maybe prescribed to me by Sanders Dermatology.

The information obtained will be kept completely confidential in accordance with current ©HIPPA laws and is intended to help my provider maintain the most up-to-date information and provide the safest and most comprehensive care.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.