Dates at the seasonal address
These questions are included to comply with new Federal Health guidelines - we are required to ask for this information:
Please check how you would like to be notified: I permit Ohio Skin Care Institute to disclose my protected Health Information: for the purpose of appointments/test results/ procedure reminders and follow-up; by leaving such information in the form of a message on the following:
You may discuss any of my medical information with the following individuals: If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their names below. Only these individuals will be provided with the information. Should you wish to update the names provided below, Please ask the receptionist.