I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and that if any information I’ve provided is found to be untrue, I will be held responsible for the difference in fees. I further agree to inform San Diego Family Dermatology if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of San Diego Family Dermatology. I understand that if I no-show to one appointment, I will no longer be eligible for the Sliding Scale program and will be charged full cash rates going forward. I hereby acknowledge that I read and understand the foregoing disclosure.