Make An Appointment

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Please select any/all qualifying conditions that apply to you: *

Eczema (inflammation of skin)
Rosacea (redness of skin on face)
Rosacea (redness of skin on face)
Visible blood vessels on skin
Flushing/Blushing of skin
Skin rashes caused by sunlight
Skin Blisters caused by sunlight
Skin Redness caused by sunlight
Skin itchiness caused by sunlight

Personal Information

Name *

First

Last

Email *

Phone Number *

Date Of Birth *

How did you hear about us ?

Appointment Information

*CLOSED SATURDAY SUNDAY
*HOURS OF OPERATION ARE 10AM-5PM
*ALL APPOINTMENTS WILL BE A ONLINE VISIT

What Days Of The Week Are You Available?

Monday
Tuesday
Wednesday
Thursday
Friday

Best Time Range For The Appointment

*OPERATING HOURS ARE 10AM-5PM
*CHOOSE THE BEST TIME FRAME AND WE WILL CONFIRM APPOINTMENT

Application Information

Provide the following information as it appears on the vehicle registration, as well as the driver license ID Number

First Name

Last Name

Middle Initial

Driver License ID #

Address (Number and Street)

Apt #

City

State

Zip Code

Phone Number

Is the medical exemption for someone other than the registered owner of the vehicle?

If the tint exemption is for a vehicle that is registered under somebody other then the vehicles registered owner then select yes. Select No if you are the registered owner of the vehicle and are getting the exemption for yourself. Example: Exemption is for the registered owners (Son, Daughter, etc..)

Please Input all information of the vehicles registered owner below

First Name

Last Name

Middle Initial

Driver License #

Address (Number and Street)

Apt #

City

State

Zip Code

Phone Number

Nature of Relationship to Applicant

Example:( Son, Daughter, Husband, Wife, etc..) of the registered owner

Frequency of and reason for such persons ridership in Applicants Vehicle

Example: (Grocery, School, Work, etc...)

Todays Date

Signature

Clear Signature

Picture of Drivers License

Click or drag a file to this area to upload.

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