Cosmetic Appointment

Please complete this form and we will contact you soon to set up your cosmetic appointment.

According to the HIPAA guidelines established by the Department of Health and Human Services, unencrypted email communication is not considered secure, but is permitted if the patient acknowledges and accepts the risks inherent with this form of communication. By submitting this form you authorize Pariser Dermatology to contact you via email regarding an appointment and acknowledge and accept this risk. If you do not wish to allow us to e-mail you please contact us at 757-622-6315 to schedule your appointment.