Important Privacy Choices for Consumers

You have the right to control whether we share some of your personal information.

Please read the following information carefully before you make your choices below.

Your Rights

You have the following rights to restrict the sharing of personal and financial information with our affiliates (companies we own or control) and outside companies with which do business. Nothing in this form prohibits the sharing of information as required or permitted by law.

Your Choices

Restrict Information Sharing With Companies We Own or Control (Affiliates): Unless you check the box below to decline, we may share personal and financial information about you with our affiliated companies.

(_) NO, please do not share personal and financial information with your affiliated companies.

Restrict Information Sharing With Other Companies We Do Business With To Provide Financial Products And Services: Unless you check the box below to decline, we may share personal and financial information about you with outside companies we contract with to provide financial products and services to you.

(_) NO, please do not share personal and financial information with outside companies you contract with to provide financial products and services.

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Time Sensitive Reply

You may make your privacy choice(s) at any time. Your choice(s) marked here will remain unless you state otherwise. However, if we do not hear from you we may share some of your information with affiliated companies and other companies with whom we have contracts to provide products and services.

Name: ______________________________ Email address:________________________________

Account or Policy Number(s):____________________________________ (if applicable)

Signature: ___________________________________________________

Fill out, sign and send back this form to us at: DermaPlus, Inc., 1027 Hylan Boulevard, Staten Island, NY 10305 (you may want to make a copy for your records)