CERTIFICATION AND WARRANTY OF APPLICANT:

I hereby certify and warrant that I am an adult and will carefully read and truthfully answer all of the questions in the following online medical assessment. I further certify that I have completed this application with the purpose of employing the service of a UpScriptDermatology

Physician and that he will be relying on the truth and accuracy of my answers in determining whether I should have product ® supplied to me.

I understand I may receive medications which will include pharmacy instructions. These instructions may contain information about medications that are contra indicated with the use of product®.

I understand that I will receive accurate instructions and printed materials along with my prescription from a UpScriptDermatology Physician. If I fail to furnish UpScriptDermatology Physicians with my complete and accurate medical history, I have not fulfilled my legal obligation to inform properly UpScriptDermatology Physicians.

If I become aware of any significant changes to my medical condition, it is my legal responsibility to immediately notify the UpScriptDermatology Physicians and cease all use of product® until further notification.

I hereby agree to the foregoing terms and certify that the information I have provided is accurate.