This consent confirms your agreement for DermaConcepts/Environ® Skin Care to use your testimonial. 

You hereby agree as follows:

• Grant DermaConcepts/Environ® Skin Care the right to use the testimonial
• The testimonial may appear in connection with:

1. our business website, dermaconcepts.com 
2. advertising or marketing

• Identification of source of testimonial:

1. use of your name and professional title
2. use of the business name of the practice

By submitting this Consent Form, you are acknowledging your consent to the terms noted above.